Skip to main content

Full text of "The American journal of the medical sciences"

See other formats 


1 


Property  of  the 

Lancaster  City  and  County 
Medical  Society 


No 


THE 


AMERICAN  JOURNAL 

OF  THE 

MEDICAL  SCIENCES. 


EDITED  BY 

ISAAC  HAYS,  A.M.,  M.D., 

AND 

I.  MINIS  HAYS,  A.M.,  M.D. 


NEW  SERIES. 
VOL.  LXXVL 


PHILADELPHIA: 

HENET   C.  LEA. 
1878. 


69502 


Entered  according  to  the  Act  of  Congress,  in  the  year  1878,  by 

HENRY    C.  LEA, 
in  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


PHILADELPHIA: 
COLLINS,  PRINTER, 

705  Jay ne  Street. 


TO  READERS  AND  CORRESPONDENTS. 


All  communications  intended  for  insertion  in  the  Original  Department  of  this 
Journal  are  only  received  for  consideration  with  the  distinct  understanding  that 
they  are  sent  for  publication  to  this  Journal  alone,  and  that  abstracts  of  them 
shall  only  appear  elsewhere  subsequently,  and  with  due  credit.  Gentlemen 
favouring  us  with  their  communications  are  considered  to  be  bound  in  honour  to 
a  strict  observance  of  this  understanding. 

Contributors  who  wish  their  articles  to  appear  in  the  next  number  are  requested 
to  forward  them  before  the  1st  of  August. 

Compensation  is  allowed  for  original  articles  and  reviews,  except  when  illus- 
trations or  extra  copies  are  desired.  A  limited  number  of  extra  copies  (not 
exceeding  fifty)  will  be  furnished  to  authors,  provided  the  request  for  them  be 
made  at  the  time  the  communication  is  sent  to  the  Editors. 

The  following  works  have  been  received  :  — 

Die  TTcilkrafte  der  Sogenannten  Indifferenten  Thermen  insbesondere  bei  Krankheiten 
des  Nervensystems.  Von  Dr.  Wilh.  Tiieodok  v.  Renz.    Tubingen  :  Alb.  Moser,  1878. 

Beitrare  zur  Praktischen  Augenheilkunde.  Von  Dr.  J.  Hirschbekg,  Docentander 
Universitat  zu  Berlin.    Leipzig" :  Viet  &  Comp.,  1878. 

Die  Medicinal-Gesetzgebungdes  Deutschen  Reichs  und  seiner  Einzelstaaten.  Von 
Dr.  G.  M.  Kutke.    Berlin  :  Eugen  Grosser;  New  York  :  L.  W.  Schmidt,  1878. 

Zur  Behandlung  der  Blutungen  Nach  Abort.    Von  Paul  F.  Munde,  in  New  York. 

Guerison  de  Six  Aveugles-nes.  Par  M.  le  Dr.  Louis  Fialla,  Chef  du  Service  Ckirur- 
gicul  a  PH&pital  "  Philantropie."    Bucarest :  Thicl  &  Weiss,  1878. 

Etudes  Experimentales  et  Cliniques  sur  les  Traumatismes  Ceiebraux.  Par  le  Dr.  H. 
DiJRET,  Aide  d'Anatoniie  de  la  Faculte  de  Medicine,  etc.  Tome  I.  Paris:  Aux  Bu- 
reaux du  Progres  Medical,  1878.  * 

Contribution  to  the  Study  of  Symptoms  and  Therapeutics  of  "  Perforating  Ulcer" 
of  the  Stomach.    By  B.  Loxdon,  M.D.  Carlsbad. 

Clinical  Lectures  on  Stricture  of  the  Urethra  and  other  Disorders  of  the  Urinary 
Organs.  By  Reginald  Harbison,  F.R.C.S.,  Surgeon  to  the  Royal  Liverpool  Infirm- 
ary, etc.    London  :  J.  &  A.  Churchill,  1878. 

A  Practical  Treatise  on  Aural  Surgery.  By  H.  MacNaughton  Jones,  M.D.,  Sur- 
geon to  Cork  Ophthalmic  and  Aural  Hosp.,  etc.    London  :  J.  &  A.  Churchill,  1878. 

Atlas  of  the  Diseases  of  the  Skin.  By  Balmanno  Squire,  M.B.,  Surgeon  to  the 
British  Hospital  for  Diseases  of  the  Skin.   Part  I.    London  :  J.  &  A.  Churchill,  1878. 

Insanity  in  Ancient  and  Modern  Life,  with  chapters  on  its  Prevention.  By  Daniel 
Hack  Tuke,  M.D.,  F.R.C.S.,  Lond.    London  :  MacMillan  &  Co.,  1878. 

The  Throat  and  its  Diseases.  By  Lennox  Browne,  F.R.C.S.E.  Ed.,  Sen.  Surg1,  to 
Central  London  Throat  and  Ear  Hosp.,  etc.    London  :  Bailliere,  Tindall  &  Cox,  1878. 

The  Antidotal  Treatment  of  Diseases.  By  John  Parkin,  M.D.  London  :  Hard- 
wicke  &  Bogue,  1878. 

The  Pathology  of  Pulmonary  Consumption.  Three  Lectures,  by  T.  Henry  Green, 
M.D.,  F.R.C.P.,  Phys.  to  Charing  Cross  Hospital.    London  :  Henry  Renshaw,  1878. 

The  Pathology  and  Treatment  of  Membranous  Dysmenorrhoea.  By  John  Wil- 
liams, M.D.    London,  1878. 

Medical  Women ;  a  Statement  and  an  Argument.  By  Charles  West,  M.D.  Lon- 
den  :  J.  &  A.  Churchill,  1878. 

Cholera  in  Relation  to  certain  Physical  Phenomena.  By  T.  R.  Lewis,  M.B.,  and 
D.  D.  Cunningham,  M.D.    Calcutta,  1878. 

Diseases  of  the  Hip-Joint.    By  James  G.  Beavet,  F.R.C.S.,  Melbourne,  "1878. 

History  and  Progress  of  Surgery.  .By  James  G.  Beaney,  F.R.C.S.E.  Melbourne  : 
F.  F.  Bailliere,  1877. 

Personal  Protection  against  Yellow  Fever.  By  John  A.  Wegg,  M.D.  Kingston, 
Jamaica,  1878. 

Montreal  General  Hospital  Pathological  Report  for  the  year  ending  May  1,  1877. 
By  William  Osler,  M.D.    Vol.  I.    Montreal :  Dawson  Brothers,  1878. 

Nervous  Diseases  :  their  Description  and  Treatment.  By  Allan  McLane  Hamil- 
ton, M.D.,  Attending  Phys.  to  the  Epileptic  and  Paralytic  Hospital,  BlackwelPs  Island, 
N.  Y.    Philadelphia  :  H.  C.  Lea,  1878. 

A  Manual  of  Operative  Surgery.  By  Lewis  A.  Stimson,  B.A.,  M.D.,  Surgeon  to 
the  Presbyterian  Hospital,  New  York.    Philadelphia  :  H.  C.  Lea,  1878. 

Lectures  on  Diseases  of  the  Nervous  System.  Delivered  at  Guy's  Hospital.  By 
Samuel  Wilks,  M.D.,  F.R.S.    Philadelphia  :  Lindsay  &  Blakiston,  1878. 


8 


TO  READERS  AND  CORRESPONDENTS. 


Handbook  of  Ophthalmology.  By  Prof.  C.  Schweigger,  of  the  University  of  Ber- 
lin.   Translated  from  the  third  German  Edition  bv  Porter  Farley,  M.D.,  Rochester, 

N.  Y.    Philadelphia  :  J.  B.  Lippincott  &  Co.,  1878. 

Atlas  of  Skin  Diseases.  By  Louis  A.  Duhrixg,  M.D.,  Prof,  of  Skin  Dis.  in  Hospi- 
tal of  Univ.  of  Penna.    Part  III.    Philadelphia  :  J.  B.  Lippincott  &  Co.  1878. 

Congenital  Occlusion  and  Dilatation  of  Lymph  Channels.  By  Samuel  C.  Busey, 
M.D.,  Prof,  of  Theory  and  Prac.  of  Med.  Univ.  of  Georgetown,  etc.  New  York: 
William  Wood  &  Co.,  1878. 

Studies  on  Pathological  Anatomy.  By  Fraxcis  Delafield,  M.D.  No.  5.  New- 
York  :  William  Wood  &  Co.,  1878. 

Visions  :  a  Study  of  False  Sight.  By  Edward  H.  Clarke,  M.D.  With  an  Intro- 
duction and  Memorial  Sketch  by  Oliver  Wexdell  Holmes,  M.D.  Boston  :  Hough- 
ton, Osgood  &  Co.,  1878. 

Abbreviations  of  Titles  of  Medical  Periodicals  to  be  used  in  the  Subject^Catalogue 
of  the  Library  of  the  Surgeon-General's  Office.    Washington,  1878. 

Prescription  Writing.  By  Frederic  Hexry  Gerrish,  M.D.  Second  Ed.  Port- 
land :  Loring,  Short  and  Harmon,  1878. 

Report  and  Remarks  on  a  Fourth  and  a  Fifth  Hundred  of  Cataract  Extractions,  ac- 
cording to  Von  Graefe's  Method.    By  H.  Kxapp,  M.D.    New  York,  1877. 

Suicide  not  Evidence  of  Insanity.    By  Hon.  O.  N.  Palmer,  of  New  York. 

Kolpokleisis  as  a  means  of  Treating  Vesico-Vaginal  Fistule.  Is  the  Procedure  ever 
Necessary?    By  Natiiax  Bozem.vx,  M.D.    Philadelphia:  1877. 

On  Kolpokleisis  and  other  allied  Procedures  as  a  means  of  Treating  Vesico-Vaginal 
Fistule.    By  Nathax  Bozemax,  M.D.    Louisville,  1877. 

Cholera  of  1873.    By  W.  R.  Sevier,  M.D.,  Jonesboro,  Tennessee. 

On  the  Immunity  of  certain  Mothers  of  Children  Affected  with  Hereditary  Syphilis. 
By  James  Nevixs  Hyde,  A.M.,  M.D.    New  York,  1878. 

Relations  of  Svphilis  to  the  Public  Health.  By  Frederic  R.  Sturgis,  M.D.,  of  New 
York.    New  York,  1877. 

The  Paralysis  of  Pott's  Disease.    By  V.  P.  Gibxey,  M.D.    Chicago,  1878. 

The  Medical  Expert.  By  W.  J.  Coxklix,  M.D.,  of  Dayton,  Ohio.   Columbus,  1878. 

Is  Modern  Education  Exerting  an  Evil  Influence  upon  the  Eyesight  of  our  Children  ? 
By  A.  W.  Calhoux,  M.D.    Atlanta,  1878. 

"  What  am  I  ?"    By  J.  M.  Bodine,  M.D.    Louisville,  1878. 

Note  on  Hydrobromic  Acid.    By  Edward  R.  Squibb,  M.D.    Brooklyn,  1878. 

Fees  of  Experts.    By  T.  M.  Stevexs,  M.D.,  of  Indianapolis,  Ind. 

Tumour  of  Male  Breast  and  Cyst  of  Neck.  By  J.  H.  Pooley,  M.D.  Columbus,  1878. 

Dangers  from  Colour-Blindness  in  Railroad  Employes  and  Pilots.  By  B.  Joy  Jef- 
fries, M.D.    Boston,  1878. 

Old  Age  ;  its  Diseases  and  its  Hygiene.    By  L.  P.  Yaxdell,  M.D.  Louisville,  1878. 

The  Intra-venous  Injection  of  Milk  as  a  Substitute  for  the  Transfusion  of  Blood. 
Laparo-Electrotomy ;  a  substitute  for  the  Caesarean  Section.  By  T.  Gaillard 
Thomas,  M.D.    New  York,  1878. 

A  Clinical  Contribution  to  the  Study  of  Post-Paralytic  Chorea.  A  Contribution  to 
the  Study  of  Localized  Cerebral  Lesions.  A  Contribution  to  the  Therapeutics  of 
Migraine.    By  E.  C.  Seguix,  M.D.    New  York,  1878. 

A  Contribution  to  the  Pathological  Anatomy  of  Disseminated  Cerebro-Spinal  Scle- 
rosis.   By  Drs.  E.  C.  Seguix,  J.  C.  Shaw,  and  A.  Vax  Derveer.    Chicago,  1878. 

Faulty  Innervation  as  a  Factor  in  Skin  Diseases.  Auto-Inoculation  of  Vegetable 
Parasites  of  the  Skin.    By  Edward  Wigglesworth,  M.D.    New  York,  1878. 

Objections  to  the  Use  of  Carbolic  Acid  in  the  Treatment  of  Piles.  By  J.  M.  Mathews, 
M.D.    Louisville,  1878. 

A  Review  on  the  Treatment  of  Fracture  of  the  Femur.  B3-  Edward  Borck,  M.D. 
St.  Louis,  1878. 

Scarlatina  in  Chicago.  The  Etiology  of  Intemperance.  By  Chas.  W.  Earle,  M.D. 
Chicago. 

Lithotomy.    By  David  Prixce,  M.D. 

On  the  Relation  of  Moisture  in  Air  to  Health  and  Comfort.   By  Robt.  Briggs,  C.  E. 

Amputation  of  Cervix  Uteri.  Clinical  Gvngecology,  Sterility,  and  its  Treatment. 
By  W.  H.  Wathex,  M.D.    Louisville,  1878. 

Subperiosteal  Excision  of  the  Entire  Scapula  and  Head  of  the  Humerus.  Recovery. 
By  Charles  B.  Brigham.    Cambridge,  1S78. 

Fluid  Extracts  by  Repercolation.  By  Edward  R.  Squibb,  M.D.  Philadelphia.  1878. 

Metric  Weights  and  Measures  for  Medical  and  Pharmacal  Purposes.    Wash.  187S. 

An  Address  Commemorative  of  Nathan  R.  Smith,  M.D.  B}T  S.  C.  Chew,  M.D. 
Baltimore,  1878. 

Dislocation  of  Shoulder-Joint  caused  by  Muscular  Spasm.    Dislocation  of  Femur 
on  Dorsum  Ilii  Reduced  by  Manipulation.    By  A.  B.  Cook,  M.D.    Louisville,  1878. 
Proceedings  of  the  Medical  Society  of  Delaware,  June,  1877. 
Proceedings  of  the  Louisiana  State  Medical  Association,  1878. 
Transactions  of  the  American  Dermatological  Association,  1877.    New  York.  1S7S. 


TO  READERS  AND  CORRESPONDENTS. 


9 


Transactions  of  the  Vermont  Medical  Society,  1877.    St.  Albans,  1878. 

Proceedings  of  the  Therapeutical  Society  of  New  York.    Fascic.  1,  2. 

Proceedings  of  the  Medical  Society  of  the  County  of  Kings,  April,  May,  June,  1878. 

Proceedings  of  Academy  of  Natural  Sciences  of  Philadelphia,  Sept.  to  Dec.  1877. 

Report  of  the  Massachusetts  General  Hospital,  1877.    Boston,  1878. 

Report  of  the  Brooklyn  E}re  and  Ear  Hospital,  1878. 

Report  of  the  Wills  Eye  Hospital,  1877.    Philadelphia,  1878. 

Report  of  New  York  Hospital  and  Bloomingdale  Asylum  for  1877.  New  York,  1878. 
Report  of  New  York  Society  for  Relief  of  Ruptured  and  Crippled.  New  York,  1878. 
Report  of  St.  Michael's  Hospital.    Newark,  1878. 

Report  of  the  State  Asylum  for  Insane  Criminals.    Auburn,  N.  Y.,  1878. 
Report  of  the  Retreat  for  the  Insane  at  Hartford,  Conn.,  1878. 
Report  of  the  Dayton  Hospital  for  the  Insane.    Columbus,  1878. 
Report  of  Brigham  Hall,  1877.    Canandaigua,  1878. 
Report  of  the  State  Lunatic  Asylum,  Utica,  N.  Y.,  1877.    Utica,  1878. 
Nova  Scotia  Hospital  for  the  Insane.    Report  for  1877. 
Report  of  the  Connecticut  Hospital  for  the  Insane.    Middletown,  1878. 
Report  of  Asylum  for  Relief  of  Persons  Deprived  of  Use  of  their  Reason.  Phila.,  1878. 
Report  of  the  State  Board  of  Health  of  Massachusetts,  Jan.  1878.    Boston,  1878. 
Report  of  the  Board  of  Health  of  the  City  of  Dayton.    Dayton,  1878. 
Report  of  the  Board  of  Health  of  the  City  of  Pittsburg,  1877.    Pittsburg,  1878. 
Sixth  Annual  Report  of  the  Secretary  of  the  State  of  Michigan,  relating  to  the  Reg- 
istry and  Return  of  Births,  Marriages,  and  Deaths,  for  the  year  1872.    Lansing,  1877. 

The  following  Journals  have  been  received  in  exchange  : — 

Deutsches  Archiv  fur  Klinische  Medicin.  Bd.  XX. ,  Heft  5, 6.  Bd.  XXI. ,  Heft  1  to  4. 
Archiv  der  Heilkunde.    Bd.  XIX.,  Heft  1,  2,  3. 

Centralblatt  fur  die  Medicinischen  Wissenschaften.    Nos.  49,  1877,  to  22, 1S78. 
Allgemeine  Wiener  Medizinische  Zeitung.    Nos.  50,  1877,  and  1  to  22, 1878. 
Deutsche  Medicinische  Wochenschrift.  "Nos.  49  to  52,  1877,  and  1  to  22,  187S. 
Upsala  Lokareforenings  FSrhandlingar.    Bd.  XIII.,  Nos.  2,  3,  4. 
Bibliothek  for  La?<rer.    Bind  VIII.,  1,  2. 

Nordiskt  Medicinskt  Archiv.    Bd.  IX.,  Fjarde  Haftet,  Bd.  X.,  Forsta  Haftet. 
Annali  Universali  di  Medicina  e  Chirurgia.    Dec.  1877,  to  Maggio,  1878. 
Giornale  Italiano  delle  Malattie  Venneree  e  della  Pelle.    Dec.  1877,  to  Aprile,  1878. 
Commentario  Clinico  di  Pisa.    Nov.,  Dec.  1S77,  Gen.,  Feb.,  Marzo,  Aprile,  1878. 
L'Imparziale.    Nos.  23,  24, 1877, 1  to  10,  1878. 
Lo  Sperimentale.    Fascic.  12,  1877, 1  to  5, 1878. 

La  Medicina  Contemporanea  Nuova  Rivista  Italiana  e  Straniera.  Feb.  to  Mazzio,  1878. 

O  Correio  Medico  de  Lisboa.    Nos.  21,  1877  ,  2  ,  3,  4,  6,  1878. 

Revista  d'Aero  e  Climatoterapia.    Gennaio,  Febbrajo,  Marzo,  1878. 

Cronica  Medico-Quirur«-ica  de  la  Habana.    Nos.  1,  2,  3,  1878. 

La  Gaceta  Cientifica  de"  Venezuela.    Nos.  12,  13, 1877,  1  to  19, 1878. 

Archives  Generales  de  Medecine.    Feb.  to  Juin,  1878. 

Revue  des  Sciences  Medicales  en  France  et  de  l'Etranger.    Jan.,  Avril,  1878. 
Revue  Mensuelle  de  Medecine  et  de  Chirurgie.    Dec.  1877,  to  Mai,  1878. 
Annales  de  Dermatologie  et  de  Syphiligraphie.   T.  VIII.,  No.  6  ;  T.  IX.,  Nos.  1,  2,  3. 
Annales  des  Maladies  de  l'Oreille  et  du  Larynx.    Dec.  1877,  Mars,  Mai,  1878. 
Gazette  Hebdomadaire  de  Medecine  et  de  Chirurgie.    Nos.  1  to  23, 1878. 
L'Union  Medicale.    Nos.  145  to  151, 1877,  and  1  to  66, 1878. 
Le  Progres  Medical.    Nos.  50  to  52, 1877,  and  1  to  22, 1878. 
Le  Mouvement  Medical.    Nos.  49  to  52,  1877,  and  1  to  20, 1878. 
L'Annee  Medicale.    Nos.  1  to  6, 1878. 

Revue  Scientifique  de  la  France  et  de  l'Etranger.    Nos.  24  to  49, 1878. 

Union  Medicale  et  Scientifique  du  Nord-Est.  Oct.  1877,  Jan.  to  Mai,  1878. 

Revue  Internationale  des  Sciences.    Nos.  1  to  22, 1878. 

The  Retrospect  of  Medicine.    July  to  Dec.  1877. 

The  Lancet.    Jan.  to  June,  1878. 

The  Medical  Times  and  Gazette.    Jan.  to  June,  1878. 

The  British  Medical  Journal.    Jan.  to  June,  1878. 

The  Medical  Examiner.    Jan.  to  June,  1878. 

The  London  Medical  Record.    Jan.  to  May,  1878. 

The  Sanitarv  Record.    Jan.  to  June,  1878. 

The  Practitioner.    Nov.,  Dec.  1877,  Jan,  to  May,  1878. 

The  Obstetrical  Journal  of  Great  Britain.    Jan.  to  June,  1878. 

The  London  Ophthalmic  Hospital  Reports.   Dec.  1877. 

The  Journal  of  Anatomy  and  Physiology.    Jan.  1878. 

The  Journal  of  Psychological  Medicine   Vol.  IV.,  Pt.  1. 

Brain  :  A  Journal  of  Neurology.,   April,  1878. 

Edinburgh  Medical  Journal.  "Nov.,  Dec.  1877,  Jan.  to  May,  1878. 

The  Glasgow  Medical  Journal.    Oct.  1877,  Jan.,  Feb.,  March,  May,  June,  1878. 


10 


TO  READERS   AND  CORRESPONDENTS. 


The  Dublin  Journal  of  Medical  Science.    Nov.,  Dec.  1877,  Jan.  to  May,  1378. 

The  Doctor.    Jan.  to  June,  1878. 

The  Indian  Medical  Gazette.    Dec.  1877,  Jan.  1878. 

The  Australian  Medical  Journal.    June  to  Sept.  1878. 

The  Australian  Practitioner.    Jan.  1878. 

Canada  Medical  and  Surgical  Journal.    Jan.  to  May,  1878. 

The  Canada  Medical  Record.    Dec.  1877,  to  April,  1878. 

The  Canadian  Journal  of  Medical  Science.    Jan.  to  June,  1878. 

The  Canada  Lancet.    Jan.  to  June,  1878. 

L'Union  Melicale  du  Canada.    Jan.  to  Juin,  1878. 

The  Boston  Medical  and  Surgical  Journal.    Jan.  to  June,  1878. 

The  New  York  Medical  Journal.    Jan.  to  June,  1878. 

The  Medical  Record.    Jan.  tp  June,  1878. 

The  American  Journal  of  Insanity.    Jan.,  April,  1878. 

The  American  Journal  of  Obstetrics.    Jan.,  April,  1878. 

Archives  of  Dermatology.    Jan.,  April,  1878. 

The  Hospital  Gazette.    Jan.  to  June,  1878. 

Buffalo  Medical  Journal.    Jan.  to  June,  1878. 

Monthly  Abstract  of  Medical  Science.    Jan.  to  June,  1878. 

Medical  News  and  Library.    Jan.  to  June,  1878. 

Philadelphia  Medical  Times.    Jan.  to  June,  1878. 

Medical  and  Surgical  Reporter.    Jan.  to  June,  1878. 

Half-Yearly  Compendium  of  Medical  Science.    Jan.  1878. 

Cincinnati  Lancet  and  Observer,    Jan.  to  June,  1878. 

Cincinnati  Medical  News.    Jan.  to  June,  1878. 

The  Clinic.    Jan.  to  June,  1878. 

The  Ohio  Medical  and  Surgical  Journal.    Feb.,  April,  1878. 

Ohio  Medical  Recorder.    Jan.  to  May,  L878. 

The  American  Practitioner.    Jan.  to  June,  1878. 

The  Chicago  Medical  Journal.    Jan.  to  June,  1878. 

The  Journal  of  Nervous  and  Mental  Diseases.    Jan.,  April,  1878. 

Detroit  Lancet.    Jan.  to  June,  1878. 

Michigan  Medical  News.    Jan.  to  June,  1878. 

St.  Louis  Medical  and  Surgical  Journal.    Jan.  to  June,  1878. 

Saint  Louis  Clinical  Record.    Jan.  to  June,  1878. 

Toledo  Medical  and  Surgical  Journal.    Jan.  to  May,  1878. 

Pacific  Medical  and  Surgical  Journal.    Jan.  to  June,  1878. 

Western  Lancet.    March,  April,  May,  1878. 

Maryland  Medical  Journal.    Jan.  to  June,  1878. 

Virginia  Medical  Monthly.    Jan.  to  June,  1878. 

North  Carolina  Medical  Journal.    Jan.  to  April,  1878. 

Southern  Medical  Record.    Jan.  to  April,  1878. 

Atlanta  Medical  and  Surgical  Journal,    Jan.  to  May,  1878. 

New  Orleans  Medical  and  Surgical  Journal.    Jan.  to  June,  1878. 

Richmond  and  Louisville  Medical  Journal.    Feb.  to  May,  1878. 

The  Louisville  Medical  News.    Jan.  to  June,  1878. 

The  American  Medical  Weekly.    Jan.  to  June,  1878. 

Nashville  Journal  of  Medicine  and  Surgery,    Jan.  to  May,  1878. 

The  Quarterly  Journal  of  Inebriety.    March,  June,  1878. 

The  Sanitarian.    Jan.  to  June,  1878. 

American  Journal  of  Pharmacy.    Jan.  to  June,  1878. 

Druggists'  Circular.    Jan.  to  June,  1878. 

The^Pharmacist.    Jan.  to  May,  1878. 

Dental  Cosmos.    Jan.  to  June,  1878. 

American  Journal  of  Dental  Science.    Jan.  to  June,  1878. 
American  Journal  of  Science  and  Arts.    Jan.  to  June,  1878. 
The  Journal  of  the  Franklin  Institute.    Jan.  to  June,  1878. 
Boston  Journal  of  Chemistry.    Jan.  to  June,  1878. 


Communications  intended  for  publication,  and  books  for  review,  should  be  sent 
free  of  expense,  directed  to  Isaac  Hats,  M.D.,  Editor  of  the  American  Journal  of  the 
Medical  Sciences,  care  of  Mr.  Henry  C.  Lea,  Philadelphia.  Parcels  directed  as  above, 
and  (carriage  paid)  under  cover,  to  Mr.  Charles  J.  Skeet,  Bookseller,  No.  10  King 
William  Street,  Charing  Cross,  London,  will  reach  us  safely  and  without  delay. 

All  remittances  of  money  and  letters  on  the  business  of  the  Journal  should  be  ad- 
dressed exclusively  to  the  publisher,  Mr.  H..C.  Lea,  No.  706  Sansom  Street. 

The  advertisement  sheet  belongs  to  the  business  department  of  the  Journal,  and  all 
communications  for  it  must  be  made  to  the  publisher. 


CONTENTS 


OF 

THE  AMERICAN  JOURNAL 

OF 

THE  MEDICAL  SCIENCES. 
NO.  CLI.  NEW  SERIES. 

JULY,  1878. 


ORIGINAL  COMMUNICATIONS. 
MEMOIRS  AND  CASES. 

ART.  PAGE 

I.  On  a  Rare  Yaso-motor  Neurosis  of  the  Extremities,  and  on  the  Maladies 
with  which  it  may  be  confounded.  By  S.  Weir  Mitchell,  M.D.,  of  Phila- 
delphia, Member  of  the  National  Academy  of  Sciences.         .       .  .17 

II.  A  Case  of  Spaying  for  Fibroid  Tumour  of  the  Womb.  By  William 
Goodell,  A.M.,  M.D.,  Professor  of  Clinical  Gynaecology  in  the  University 

of  Pennsylvania.    ....  ......  36 

III.  On  the  Treatment  of  Uterine  Fibroids  with  Galvanism  by  Profound 
Puncture.  Illustrated  by  fifty  cases  occurring  in  the  practice  of  Gilman 
Kimball,  M.D.,  of  Lowell,  and  Ephraim  Cutter,  M.D.,  of  Cambridge, 
Mass.    Reported  by  E.  Cutter,  M.D   .50 

IV.  The  Operation  of  G astro- Hysterotomy  (True  Caesarean  Section) 
Viewed  in  the  Light  of  American  Experience  and  Success,  with  a  Record 
of  Cases  Largely  obtained  by  Correspondence.  By  Robert  P.  Harris, 
M.D.,  Member  of  the  Am.  Philosophical  Soc.  ;  Fellow  of  Coll.  of  Phy- 
sicians, Philadelphia  ;  Member  of  Philadelphia  Obstetrical  Society,  etc.  .  68 

V.  Pelvic  and  Abdominal  Abscess.  By  Charles  Kelsey,  M.D.,  Assistant 
Demonstrator  of  Anatomy  at  the  College  of  Physicians  and  Surgeons, 
New  York  81 

VI.  Case  of  an  Undescribed  Form  of  Atrophy  of  the  Hair  of  the  Beard. 
By  Louis  A.  Duhring,  M.D.,  Professor  of  Skin  Diseases  in  the  University 

of  Pennsylvania,  Dermatologist  to  the  Philadelphia  Hospital,  etc.    .        .  88 

VII.  A  Gunshot  Wound  of  the  Face,  together  with  the  Description  of  a 
Splint  adapted  for  Compound  Fractures  of  the  Upper  Jaw.  By  W.  F. 
Muhlenberg,  M.D.,  of  Reading,  Pa  92 

VIII.  Case  of  Extirpation  of  the  Scapula  with  a  Portion  of  Clavicle  and 
Entire  Arm.    By  F.  Gundrum,  M.D.,  of  Ionia,  Michigan.     .       .  .98 

IX.  Case  of  Excision  of  the  Entire  Scapula  for  Cancerous  Disease.  Re- 
covery of  the  Patient  with  a  Useful  Arm.  By  George  A.  Peters,  M.D., 
Attending  Surgeon  New  York  Hospital,  New  York.       .       .       .       .  100 

X.  Sphygmographic  Experiments  upon  a  Human  Brain,  exposed  by  an 
Opening  in  the  Cranium.  By  Mary  Putnam  Jacobi,  M.D.,  of  New 
York  .103 

XI.  A  Contribution  to  the  Pathology  of  Orbital  Cellulitis.  By  Charles 
Stedman  Bull,  A.M.,  M.D.,  Surgeon  to  the  New  York  Eye  Infirmary 
and  to  Charity  Hospital.        .        .       .       .       .       .       .        .  .112 


12 


CONTEXTS. 


ART.  PAGE 

XII.  Cases  of  Lesion  of  the  Base  of  the  Brain.  I.  Softening  of  Corpus 
Striatum ;  Hemiplegia  not  Developed  until  near  the  Termination.  II. 
Tumour  Invading  Optic  Thalamus  without  loss  of  Sensibility,  but  with 
loss  of  Co-ordination.  Cerebellar  Softening.  By  Frank  Woodbury,  M.D., 
Assistant  in  Charge  of  the  Medical  Dispensary  of  the  Jefferson  Medical 
College;  Physician  to  the  German  Hospital,  Philadelphia,  etc.       .       .  125 

XIII.  Cold  Water  Enemata  as  a  Therapeutic  Agent  in  Chronic  Diarrhoea. 
By  Michael  J.  B.  Messemer,  M.D.,  Physician  for  Internal  Diseases  in 

the  Out-door  Department  of  the  Mount  Sinai  Hospital,  New  York.         .  133 

XIV.  Harvey  and  the  Transit  of  the  Blood  from  the  Arteries  to  the  Veins 
"Per  Porositat.es."  By  W.  S.  Forbes,  M.D.,  Senior  Surgeon  to  the 
Episcopal  Hospital,  Philadelphia  138 

XV.  Is  Consumption  Contagious  ?  By  Edgar  Holden,  M.D.,  Ph.D.,  Presi- 
dent of  the  Medical  Department  of  the  Mutual  Benefit  Life  Insurance  Com- 
pany, Newark,  Xew  Jersey.  .       .       .       .       .       .       .       .  .145 

XVI.  On  the  Importance  of  Combining  Morphia  with  Quinia  in  the  Treat- 
ment of  Malarial  Fevers.  By  Meriwether  Lewis,  M.  A.,  M.D.,  of  Lenoir, 
Tennessee  159 


REVIEWS. 

XVII.  Claude  Bernard  and  his  Physiological  Works.        .       .       .  .101 

XVIII.  Higher  Medical  Education. 

1.  Practical  Essays  on  Medical  Education  and  the  Medical  Profession  in 

the  United' States.    By  Daniel  Drake,  M.D.,  Cincinnati,  1832. 
8vo. 

2.  Lectures  on  Medical  Education.    By  Samuel  Chew,  M.D.,  Phila- 

delphia, 18G4.  8vo. 

3.  Contributions  to  the  History  of  Medical  Education  and  Medical  In- 

stitutions in  the  United  States  of  America,  17  76-1876.    By  X.  S. 
Davis,  A.M..  M.D..  Washington,  1877.  8vo. 

4.  Higher  Medical  Education,  the  True  Interest  of  the  Public  and  the 

Profession.  An  Address  Introductory  to  the  112th  Course  of  Lec- 
tures in  the  Medical  Department  of  the  University  of  Pennsylvania. 
By  William  Pepper,  A.M.,  M.D.  Philadelphia":  J.  B.  Lippincott 
&'Co.,  1877.  8vo. 

5.  De  1' organisation  des  Fa'cultes  de  MSdecine  en  Allemagne.    Par  le 

docteur  Jaccoud,  Paris,  1864.  8vo. 

6.  Les  hautes  6tudes  pratiques  dans  les  Universit6s  Allemandes.  Par 

Adolphe  Wurtz,  Paris,  1870.  4to. 

7.  Etude  sur  1' organisation  de  la  Medecine  en  France  et  a.  Tetranger. 

Par  Leon  Le  Fort,  Paris,  1874.  8vo. 

8.  Ueber  das  Lehren  unci  Lernen  die  Medicinischen  Wissenschafteii  an 

den  Universitaten  der  Deutschen  Xation.    Von  Dr.  Th.  Billroth. 
Wien,  1876.  Svo. 

9.  L'enseignement  de  la  Medecine  en  Allemagne.    Par  Louis  Fiaux, 

Paris,  1877.  8vo. 

10.  De  la  situation  de  l'enseignement  Medical  en  France.    Par  Chauf- 

fard,  Rev.  des  Deux  Mondes,  Jan.  1,  1878. 

11.  Medical  Politics  ;  being  the  Essay  to  which  was  awarded  the  first  Car- 

michael  Prize,  1873.    By  Isaac  Ashe,  M.D.  (etc.),  Dublin,  1875. 
8vo. 

12.  Report  of  Proceedings  of  the  Meeting  of  the  General  Medical  Council 

in  1877.    Med.  Times  and  Gaz.,  May  and  June,  18  77.         .        .  174 

XIX.  The  Retinal  Red  and  its  Relation  to  the  Sensation  of  Sight.  Zur 
Anatomie  und  Physioiogie  der  Retina.    Von  F.  Boll.    Berliner  Acad. 

Monatsberichten,  1876.    S.  A.  5  Stn. 
Zur  Photochemie  der  Xetzhaut.    Von  W.  Kiihne.     Uber  den  Sehpur- 
pur.    Von  W.  Kiihne.    Erganzungsheft  zu  den  Verhandlungen  des 
Xaturhistorisch-medicinischen  Vereins  zu  Heidelberg.     B.  1,  K.  1, 
1877. 


CONTENTS. 


13 


ART.  PAGE 

Zur  Physiologic  des  Sehens  und  der  Farbencmpfindimg.    Von  F.  Boll. 

Berl.  Akad.  Monatsber.,  11  Jan.  1877,  7  Stn. 
Nachtragliche  Zusatze  zn  dieser  Mittheilung.    Ebendas,  15  Feb.  3  Stn. 
Der  Sehpurpur  beobachtet  im  Auge  eines  gehenkten  Menschen.  Yon 

Prof.  Schenk  und  Dr.  Zuckerkandl.    Allgemeine  Wien.  Zeitschrift, 

N.  11,  1877. 

Zur  Farbe  der  Netzhaut.  Yon  E.  Fuchs.  AVien.  Med.  AA'och.  N.  11, 
1877. 

Ueber  die  Verbreitiing  des  Sehpurpurs  im  Menschlichen  Auge.  Yon  W. 
Kuhne.  AVeitere  Beobachtungen  uber  den  Sehpurpur  des  Menschen. 
Yon  W.  Kuhne.  Das  Sehen  ohne  Sehpurpur.  Yon  W.  Kuhne. 
Untersuchungen  liber  den  Sehpurpur.  Yon  A.  Ewald  und  AY.  Kiihne. 
Erganzungsheft  z.  d.  Verhand.  des  Nat. -Hist. -Med.  Yereins  zu  Heidel- 
berg, B.  1,  H.  2,  1877. 

Ophthalmoscopische  Mittheilungen  uber  den  Purpur  der  Retina.  Yon 
Dr.  Helfreich.    Centralblatt  f.  Medic.  Wissen.  X.  7,  1877. 

Untersuchunsen  liber  die  AYahrnehmbarkeit  des  Sehpurpurs  mit  deni 
Ophthalmoskope.  Yon  Dr.  M.  J.  Diet!  und  Dr.  Ferd.  Plenk.  Cen- 
tralblatt fur  die  Med.  Wissen.,  16,  1877. 

Ueber  die  Diagnose  des  Sehpurpurs  im  Leben.  Yon  Dr.  E.  A.  Coccius. 
Leipzig,  3  Juni,  1877. 

Ueber  die  Darstellung  von  Optogrammen  im  Froschauge.  Yon  AY. 
Kiihne.  Untersuchungen  liber  den  Sehpurpur.  Yon  A.  Ewald  und 
W.  Kiihne.  Erganzungsh.  z.  d.  Yerhand.  des  Naturhist.-Med.  Yereins 
zu  Heidelberg,  B.  1,  H.  3,  1877. 

Zur  Anatomic  und  Physiologic  der  Retina.  Yon  F.  Boll.  Arch.  f. 
Anat.  u.  Physiol.    Physiolog.  Abth.,  1877.    S.  4-3G. 

Zur  Lehre  vom  Lichtsinne.  Von  E.  Hering.  Wiener  Sitzungsberichte, 
v.  66,  68,  69,  1872-1874. 

Die  Macula  lutea,  anatomisch  und  ophthalmoscopisch.  Von  Herm. 
r  Schmidt-Rimpler.    Arch.  f.  Ophthal.,  xxi.  3,  p.  17,  1876. 

Etudes  chimico-physiologiques  sur  les  matieres  colorantes  de  la  r6tine. 
Par  Stefano  Capranica.  Annates  d'Oculistique,  T.  lxxviii.,  p.  144, 
1877.        .       .   190 

ANALYTICAL  AND  BIBLIOGRAPHICAL  NOTICES. 

XX.  Saint  Bartholomew's  Hospital  Reports.  Edited  bv  W.  O.  Church, 
M.D.,  and  Alfred  Willett,  F.R.C.S.  Vol.  XIII.  8vo.  pp.  xxiv.,  354, 
126.    London:  Smith,  Elder  &  Co.,  1877   199 

XXI.  Transac  tions  of  the  Obstetrical  Society  of  London.  Vol.  XIX.  For 
the  year  187  7.    8vo.  pp.  279.    London:  Longmans,  Green  &  Co.,  1878.  207 

XXII.  On  the  Source  of  Muscular  Power :  Arguments  and  Conclusions 
drawn  from  Observations  upon  the  Human  Subject  under  Conditions  of 
Rest  and  of  Muscular  Exercise.  By  Austin  Flint,  Jr.,  M.D.,  Prof,  of 
Physiology  and  Physiological  Anatomy  in  the  Bellevue  Hospital  Medical 
College,  New  York,  etc.  12mo.  pp.  103.  New  York:  D.  Appleton  & 
Co.,  1878   %  214 

XXIII.  Albrecht  von  Graefe  :  Sein  Leben  und  AVerken.  Von  Dr.  Eduard 
Michaelis,  Augenarzt  in  Berlin.  Berlin:  Druck  und  Verlag  von  G.  Rei- 
mer.    pp.  196,  1877. 

Albrecht  von  Grafe  :  His  Life  and  AArorks.    By  Edward  Michaelis.    .  .216 

XXIV.  Lectures  on  Medical  Jurisprudence.  By  Francis  Ogston,  M.D., 
Professor  of  Medical  Jurisprudence  and  Medical  Logic  in  the  University 
of  Aberdeen.  Edited  by  Francis  Ogston,  Junior,  M.D.,  Assistant  to  the 
Professor  of  Medical  Jurisprudence,  and  Lecturer  on  Practical  Toxicology 
in  the  L^niversity  of  Aberdeen.  8vo.  pp.  xii.,  663.  Philadelphia:  Lind- 
say &  Blakiston^  1878  .222 

XXV.  Guerison  de  Six  Aveugles-nes.  Par  M.  le  Dr.  Louis  Fialla,  Chef 
du  Service  Chirurgical  a  l'Hopital  Philanthropic.  8vo.  pp.  32.  Bucarest, 
Thiel  &  AAreiss,  1878   .       .  .227 


14 


CONTENTS. 


ART.  PAGE 

XXVI.  Illustrations  of  Clinical  Surgery.  By  Jonathan  Hutchinson,  F.R.C  ,S., 
etc.  Fasciculi IX.  and  X.  Folio,  pp.  193-244.  Philadelphia:  Lindsay  & 
Blakiston,  1878   230 

XXVII.  Atlas  of  Skin  Diseases.  By  Louis  A.  Duhring,  M.D.,  Professor 
of  Skin  Diseases  in  the  Hospital  of  the  University  of  Pennsylvania.  Phy- 
sician to  the  Dispensary  for  Skin  Diseases,  Philadelphia,  etc.  Part  111. 
Philadelphia:  J.  B.  Lippincott  &  Co.,  1878.  ....  .232 

XXVIII.  Injuries  of  the  Eye,  and  their  Medico-Legal  Aspect.    By  Ferdi- 


nand von  Arlt,  M.D.,  Professor  of  Ophthalmology  in  the  University  of 
Vienna,  Austria.  Translated,  with  the  permission  of  the  Author,  by  Chas. 
S.  Turnbull,  M.D.,  Surgeon  to  Eye  and  Ear  Department,  Howard  Hos- 
pital, etc.  12mo.  pp.  198.  Philadelphia:  Claxton,  Remsen  &  Haffel- 
finger,  1878.   232 

XXIX.  A  Practical  Treatise  on  Aural  Surgery.  By  H.  Macnaughton 
Jones,  M.D.,  etc.,  Surgeon  to  the  Cork  Ophthalmic  and  Aural  Hospital, 
etc.  etc.    8vo.  pp.  174.    London:  J.  &  A.  Churchill,  1878.  .       .       .  234 

XXX.  Insanity  in  Ancient  and  Modern  Life,  with  Chapters  on  its  Preven- 
tion. By  Daniel  Hack  Tuke,  M.D.,  F.K.C.P.  12mo.  pp.  226.  London  : 
Macmilkn  &  Co.,  1878   236 

XXXI.  Montreal  General  Hospital :  Pathological  Report  for  the  Year  end- 
ing May  1,  1877.   By  William  Osier,  M.D.   8vo.  pp.  97.  Montreal,  1878.  288 

XXXII.  Mortuary  Experience  of  the  Mutual  Life  Insurance  Company  of 
New  York,  with  Tabulated  Reports,  and  an  Analysis  of  the  Causes  of 
Death.  By  G.  S.  Winston,  M.D.,  W.  R.  Gillette,  M.D.,  and  E.  J. 
Marsh,  M.D.    Vol.  II.    8vo,  pp.  224.    New  York,  1877.     .       .       .  240 

XXXIII.  On  the  Use  of  Wines  in  Health  and  Disease.  By  Francis  E. 
Anstie,  M.D.,  F.R.C. P.  12mo.  pp.  74.  London:  Macmillan  &  Co. 
1877.     .       .       .   243 

XXXIV.  Prescription  Writing,  Designed  for  the  Use  of  Medical  Students 
who  have  never  Studied  Latin.  By  Frederic  Henry  Gerrish,  M.D., 
Prof,  of  Materia  Medica  and  Therapeutics  in  the  Medical  School  of 
Maine,  etc.    Second  edition,  16mo.  pp.  51.    Portland:  Loring,  Short 


&  Harmon,  1878   244 

XXXV.  Annual  Report  of  the  Board  of  Health  of  the  City  of  Pittsburgh 

for  the  Year  1877.    pp.70.    Pittsburgh,  1878   244 

XXXVI.  Handbook  of  Ophthalmology".  By  Prof.  C.  Schweig^er,  of  the 
University  of  Berlin.  Translated  from  the  third  German  edition.  By 
Porter  Farley,  M.D.,  Rochester,  N.  Y.    8vo.  pp.  555.  Philadelphia": 

J.  B.  Lippincott  &  Co.,  1878   245 

XXXVII.  Transactions  of  the  Medical  Society  of  the  State  of  New  York 

for  the  Year  1877.    8vo.  pp.  479.    Albany,  1877.         ....  245 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES  IN  THE 
MEDICAL  SCIENCES. 


Anatomy  and  Physiology. 


page 


Note  on  a  Congenital  Band  stretch- 
ing Across  the  Origin  of  the 
Aorta.  By  Mr.  Robert  Sam- 
uels Archer.      .       .       .  .247 


Localization  of  Functions  in  the 
Spinal  Cord.    By  Luchsinger.   .  24 


CONTENTS. 


15 


Materia  Medica  and  Therapeutics. 


page 

Toxic  Properties  of  Carbolic  Acid 
in  Surgical  Use.   By  Dr.  Kiister.  248 

Therapeutical  Properties  of  Salicy- 
lic Acid.    By  H.  KShler.       '  .  2.30 


Action  of  Thermal  Applications  to 
the  Skin  upon  the  Circulation  in 
the  Brain  and  other  Organs.  By 
Dr.  Winternitz.        .       .  251 


Medicine. 


Myelogenic  Leucocythaemia.  By 
Professor  Neumann.  .  .252 

Contribution  to  the  Pathology  of 
Haemophilia.    By  Mr.  P.  Kidd.  253 

Spinal  Gout.    By  Dr.  Olliver.  .253 

Writer's  Palsy  Cured  by  Strychnia. 
By  Mr.  Annandale.  .       .        .  254 

Spasmodic  Spinal  Paralysis  in  In- 
fants.   By  Professor  Erb.         .  254 

Treatment  of  Rheumatic  Facial 
Paralysis  by  Galvanism.  By 
Dr.  J.  Mascarel.       .        .       .  255 

Chloral  Hydrate  in  Laryngismus 
Stridulus.  By  Mr.  William 
Stewart  255 

Form  of  Submucous  Laryngeal 
Hemorrhage  not  hitherto  Ob- 
served.   By  Dr.  Sommerbrodt.  255 

Exophthalmic  Goitre  Cured  by 
Galvanization  of  the  Sympa- 
thetic.   By  Dr.  Ancona.   .       .  256 

Treatment  of  Asthma  by  Subcuta- 


neous Injection  of  Arsenic.  By 
Dr.  Martelli.     .        .       .  .256 

Morbid  Local  Temperature  in 
Pleurisy.    By  Prof.  Peter.        .  256 

Diagnostic  Value  of  the  Radial  Pulse 
in  Innominate  Aneurism.  By 
Messrs.  Franck  and  Bellouard   .  258 

Case  of  Hepatic  Abscess  Opening 
into  the  Lung  :  Successful  Treat- 
ment by  Carbolic  Acid.  By  Dr. 
P.  Carrescia.     .        .       .  .259 

Diabetes  Insipidus  rapidly  Cured 
by  Ergot.         .        .       .       .  259 

Treatment  of  Obstinate  Sciatica  by 
Subcutaneous  Injections  of  Ni- 
trate of  Silver.  By  Dr.  Au- 
guste  Dureau.   .       .       .  .259 

Coloured  Exudation  in  Eczema. 
By  Dr.  Lindsay.       .        .  .260 

Urticaria  following  the  Adminis- 
tration of  Salicylate  of  Soda.  By 
Dr.  Heinlein.    .       .       .  .260 


Surgery. 


Morbid  Anatomy  of  Tetanus.  By 
Dr.  E.  Aufrecht.      .       .       .  261 

The  Union  of  Divided  Bloodves- 
sels.   By  Pfitzer.      .       .  .262 

The  Application  of  the  Antiseptic 
Method  in  Cases  where  Sepsis  is 
already  present.    By  Dr.  Konig.  2G3 

Lymphadenoma  with  Retinal  Hem- 
orrhages.   By  M.  Chauvel.       .  264 

Removal  of  an  Enormous  Lipoma. 
By  Dr.  Wolfler.        .       .  .265 

Narrowing  of  tlje  Larynx  by  Mem- 
branous Cicatrices  following  Sy- 
philis.   By  Dr.  Sommerbrodt.    .  266 

Enterotomy.  By  Dr.  von  Lan- 
genbeck  268 

Laparotomy  under  Lister's  Anti- 
septic Method.    By  Dr.  Czerny.  268 

Operation  for  Strangulated  Femoral 
Hernia,  in  which  an  Anomalous 
Obturator  Artery  was  Divided. 
By  Mr.  Barker.        .        .  .269 

Urethritis  following  the  Use  of  Ar- 
senic.   By  M.  Saint-Philippe.  .  270 

Five  Hundred  Cases  of  Operation 


for  Stone  in  the  Bladder  of  the 
Male.    By  Sir  Henry  Thompson.  271 

Treatment  of  Hydrocele  by  Elec- 
tricity.   By  Signor  Macario.      .  272 

Disarticulation  of  Hip.  By  M. 
Verneuil.  .        .       .  .272 

Treatment  of  Aneurism  of  the  Aor- 
ta by  Electro-Puncture.  By  M. 
Dujardin-Beaumetz.  .        .  .274 

The  History  of  Complete  Extirpa- 
tion of  the  Scapula.  By  Dr.  von 
Adelmann.        ....  275 

Extirpation  of  the  Scapula  and  a 
Portion  of  the  Clavicle.  By  Dr. 
Nedopil.   .       .       .       .       .2  75 

Resection  of  the  Ribs  in  Cases  of 
Retrocostal  Abscess.  By  Dr. 
Lossen.     .       .       .       .  .276 

Disarticulation  at ,  the  Knee-joint. 
By  Dr.  von  Langenbeck.  .  .277 

Epicondylar  Fractures  of  the  Hu- 
merus.   By  Dr.  E.  Zuckerkandl.  278 

Intermittent  Hydarthrosis  of  the 
Knee.  By  MM.  Panas  and 
Verneuil.  .        .       .        .       .27  9 


16 


CONTENTS. 


Ophthalmology  axd  Otology. 


Transverse  Calcareous  Film  of  the 
Cornea.  By  Mr.  Edward  Net- 
tleship.     .       .       .       .  .279 

Removal  of  Piece  of  Iron  from  the 
Lens  bv  means  of  a  Magnet.  By 
Mr.  McHardy.  .  280 


PAGE 

Cases  of  Myopia.  Bv  M.  Hatten- 
hoff.         .       .  .  .281 

Amyl-Nitrite  in  Tinnitus  Aurum. 
By  Michael  281 


Midwifery  axd  Gynecology. 

Normal  Pregnancy  and  Accouche-  Joints  in  Women.    By  Mr.  Da- 

ment  during  an   Extra-Uterine  vies  Colley.      ....  284 

Pregnancy  of  Seven  Years' Dura-  Nigrinism.    By  Woronichin.        .  286 

tion.    By  Madame  Rampin.      .  282  The  Antiseptic  Method  in  Ovari- 

Traction  of  the  Lower  Jaw  in  Head-  otomy.    By  Dr.  Carl  Schroeder.  286 

last  Cases.     By  Dr.  Matthews  Ovariotomy  Performed  on  the  An- 

Duncan                                    282  tiseptic  Method,  the  Patient  be- 

Causes   of   Puerperal    Poisoning.  ing  in  a  State  of  Pyrexia:  Re- 

By  Dr.  Hervieux.     .       .       .  283  covery.    By  Dr.  John  Williams.  288 

Treatment  of  Sore  Nipples.    By  A  Case  of  Hydatid  Tumour  of  the 

Dr.  Haussmaun.        .        .       .  284  :  Pelvis,  simulating  Retro- Uterine 

Rheumatoid  Inflammation  of  the  Hematocele.    Bv  Dr.  F.  Vil- 

I     lard  289 


Medical  Jurisprudence  and  Toxicology. 

Fatal  Pistol- Shot  without  Perfora-  Sulphuric  Acid  as  an  Antidote  to 
tion  of  the  Skin.  By  Dr.  Hof-  Carbolic  Acid.  By  Dr.  Seuftle- 
mann   290  j    ben.  290 


AMERICAN  INTELLIGENCE. 

Origixal  Communications. 

Acute -Inversion  of  the  Uterus.   By  Samuel  Hall.  M.D.,  of  Reeds- 

I     burgh,  Sauk  County,  Wisconsin.  291 

Domestic  Summary. 

Laparo-Elytrotomy :    a  Substitute        j     (right)  Humerus ;  Recovery.  By 
for  the  Cesarean  Section.    By  Dr.  Charles  B.  Brigham    .       .  296 

Dr.  T.  Gaillard  Thomas.   .       .  292  Hare-lip  and  Cleft  Palate  in  the 

Intra- Venous  Injection  of  Milk  as  Negro.    By  Dr.  Middleton  Mi- 

a  Substitute  for  Transfusion  of  chel.  296 

Blood.  By  Dr.  T.  Gaillard  j  Smallpox  in  the  Pregnant  Woman 
Thomas   293  I     and  in  the  Foetus.    By  Dr.  W. 

A  Xew  Method  of  Denuding  Tis-  M.  Welch.        .       .       .  .296 

sues.  By  Dr.  Albert  H.  j  Spaying  on  account  of  Severe  Dys- 
Smith.      .....  295      menorrhoea.      By   Dr.  W.  C. 

Partial  Excision  of  Spleen.     By  Frew.       .       .       .       .  .297 

Dr  A.  A.  Faris.      .       .        .  296  i  Tracheotomy      in  Diphtheritic 

Subperiosteal  Excision  of  the  En-       ■     Croup.    By  Dr.  R.  G.  Bogue.  .  298 
tire  Scapula  and  Head  of  the 


THE 

AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES 

FOR    JULY  1878. 


Article  I. 

Ox  a  Rare  Vasomotor  Neurosis  of  the  Extremities,1  and  ox  the 
Maladies  with  which  it  may  be  confounded.  By  S.  Weir  Mitchell, 
M.D.,  of  Philadelphia,  Member  of  the  National  Academy  of  Sciences. 

A  few  years  ago  I  published  in  the  PJiiladelphia  Med.  Times  (1872, 
pp.  81  and  113)  a  brief  paper  upon  certain  painful  affections  of  the  feet, 
and  drew  attention  to  a  form  of  foot-disorder  which  I  was  unable  to  find 
fully  described  elsewhere.  This  paper  attracted  little  attention;  and  I 
now  find  myself  called  upon,  by  a  larger  and  more  fertile  knowledge,  to 
review  the  subject,  and  again  to  call  to  the  notice  of  physicians  a  some- 
what rare,  and  yet  most  interesting,  form  of  disease. 

I  have  called  it  a  rare  disease,  because,  in  a  large  experience,  I  have 
seen  but  few  cases  ;  yet  it  is  likely  that,  when  once  recognized,  it  may  be 
found  to  be  more  common  than  I  now  conceive  it  to  be. 

In  dealing  with  this  subject,  I  shall  first  draw  a  picture  of  the  malady 
as  I  have  seen  it  in  its  various  degrees  of  severity  ;  I  shall  then  relate 
eases  from  the  mildest  to  the  most  severe  ;  and  end  by  discussing  them 
from  such  points  of  view  as  they  may  suggest. 

The  patient,  nearly  always  a  man,  after  some  constitutional  disease,  like 
a  low  fever,  or  after  prolonged  physical  exertion  afoot,  begins  to  suffer 
with  pain  in  the  foot  or  feet ;  usually  it  comes  in  the  ball  of  the  foot,  or  of 
the  great  toe,  or  in  the  heel ;  and  from  these  parts  it  extends  so  as  to  in- 
volve a  large  portion  or  all  of  the  sole,  and  to  reach  the  dorsum,  and  even 
the  leg.  More  often  it  is  felt  finally  in  a  limited  region  of  one  or  both 
soles,  and  does  not  extend  beyond  these  areas.    At  first  it  is  felt  only  to- 


1  The  foot  and  hand  disorder  I  am  about  to  describe  may  be  conveniently  labelled 
Erythromelalgia  ;  ipvBpo?,  red  ;  (*s\os,  a  member ;  axyoc,  pain. 
No.  CLI.—July  1878.  2 


18 


Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  [July 


wards  night,  and  is  eased  by  the  night's  rest ;  but,  soon  or  late,  it  comes 
nearer  and  nearer  to  the  hour  of  rising  from  bed.  In  like  manner,  while 
at  first  it  is  made  to  increase  only  by  excessive  exertion  afoot,  by  and  by 
it  comes  on,  whenever  the  upright  posture  is  assumed,  or  even  when  the 
foot  is  allowed  to  hang  down.  Since,  however,  the  disease  is  not  neces- 
sarily progressive,  there  are  instances  in  which  the  pain  never  passes  a 
definite  limit.  One  case  may  for  years  have  the  trouble  only  in  the  even- 
ing ;  a  second  may  reach  and  remain  at  the  point  where  only  a  long  walk 
in  summer  causes  it ;  a  third  may  stand  still,  as  it  were,  in  a  far  more 
advanced  stage  of  the  malady,  and,  though  suffering  horrible  pain,  become 
no  worse ;  while  in  the  gravest  cases,  more  familiar  signs  of  organic  dis- 
ease of  the  spinal  cord  may  arise  to  shed  light  upon  the  pathology  of  the 
minor  forms  of  the  trouble. 

In  rare  cases,  the  first  pain  is  said  to  be  an  ache  of  the  foot ;  but  in  the 
mass  of  instances,  and  soon  or  late  in  nearly  all,  the  pain  is  of  a  burning 
character.  "  It  is  the  pain  of  a  burn  ;"  "  the  pain  of  mustard  ;"  "  of  in- 
tense sun-burn  ;"  at  least  these  are  the  phrases  used  to  describe  it,  and 
certainly  the  character  of  the  suffering  is  often  so  well  marked  as  to  be 
clinically  distinctive.  In  the  milder  cases  it  may  come  and  go,  or  be  pre- 
sent daily  at  some  time,  as  upon  exertion,  and  yet  be  but  trifling  in  its 
intensity  ;  while  in  severer  cases  the  burning  reaches  the  extreme  of  tor- 
ture. The  sufferer,  when  placed  on  his  feet,  rocks  as  if  unsteady ;  and  if 
his  eyes  be  closed,  may  deceive  the  observer  into  the  belief  that  he  has 
before  him  a  case  of  locomotor  ataxia.  Yet  a  vigorous  effort  of  will  is  fully 
competent  to  preserve  the  balance  ;  and  this  unstable  equilibrium  is  not 
seen  until,  owing  to  the  upright  posture  having  been  preserved  for  some 
minutes,  the  pain  has  risen  to  a  maximum  of  anguish. 

In  the  later  stages  of  the  disease  the  pain  is  throbbing,  aching,  and 
burning,  owing,  I  suppose,  to  the  vasal  disorders,  which  are  seen  in  some 
cases  throughout,  and  always  in  the  graver  examples. 

In  every  case,  and  at  all  stages,  the  pain  is  relieved  or  arrested  by  the 
horizontal  position,  and  by  cold.  It  is  brought  on  and  made  worse  by 
standing  or  walking ;  and,  in  bad  cases,  by  allowing  the  feet  to  hang  down  ; 
while  warmth,  and,  of  course,  heavy  feet-covers,  act  in  like  manner. 
Summer  is  usually,  not  always,  the  season  of  greatest  annoyance  ;  winter 
a  time  of  comparative  ease.  The  sufferer  sleeps  with  uncovered  feet,  and 
goes  about  without  stockings  in  his  house  ;  and  finds,  even  in  winter,  a 
light  slipper  or  a  low  shoe  comfortable. 

The  next  striking  peculiarity  of  this  disorder  is  the  flushing  of  the  part 
upon  exertion.  This  symptom,  which  is  usually  absent  in  the  very  early 
stages,  is  a  notable  feature  of  the  worst  of  the  prolonged  cases,  and  in  some 
mild  instances  can  always  be  brought  on  by  great  exertion  afoot.  In  the 
graver  examples,  the  area  of  greatest  pain  in  the  soles  or  hands  is  dis- 
tinctly and  permanently  marked  by  a  dull,  dusky,  mottled  redness,  as  if 


1878.]    Mitchell,  Rare  Vasomotor  Neurosis  of  Extremities.       1 9 


the  smaller  vessels  were  always  over-distended.  In  these  and  in  some  of 
the  less  severe  cases,  the  region  of  pain  is  in  places  tender,  and  firm  pres- 
sure by  the  finger  or  hand  will  bring  on  increased  pain,  and  even  cause 
the  whole  foot  or  hand,  or  a  part  of  it,  to  become  red,  just  as  it  does  when 
the  man  stands  up. 

The  pain  in  these  cases  is  also  entirely  inhibitory  of  walking,  and  if 
this  action  be  persisted  in,  gives  rise  to  intense  redness,  swelling  from  dila- 
tation.of  vessels,  and  finally  to  blistering  of  the  soles. 

Where  flushing  is  a  part  of  the  phenomena  of  this  interesting  malady, 
it  comes  on  during  the  erect  position  slowly  in  milder  cases,  and  almost  at 
once  in  others,  and  involves  both  veins  and  arteries.  The  foot  gets  redder 
and  redder,  the  veins  stand  out  in  a  few  moments  as  if  a  ligature  had  been 
tied  around  the  limb,  /ind  the  arteries  throb  violently  for  a  time,  until  at 
length  the  extremity  becomes  of  a  dark -purplish  tint. 

In  the  worst  cases,  when  the  patient  is  at  rest,  the  limbs  are  cold,  and 
even  pale.  The  flushing,  which,  at  first,  seems  to  be  an  active  condition, 
accompanied  with  rise  of  temperature,  in  a  few  minutes  becomes  passive  ; 
that  is,  the  arteries  cease  to  throb,  the  heat  lessens,  and  there  is  evidence 
of  lessened  oxidation. 

The  less  severe  examples  manage  to  get  along  by  rest  at  intervals,  but 
the  worst  cases  are  unable  to  stand  for  more  than  a  moment,  and  the  suf- 
ferer crawls  on  his  hands  and  knees,  keeping  his  feet  off  the  floor,  or  is 
obliged  to  be  carried  about. 

I  have  seen  lately  two  examples  in  which  the  disease  seemed  to  have 
been  progressive,  and  to  have  been  associated  in  the  later  stages  with 
distinctive  evidences  of  spinal  disease,  such  as  atrophic  states,  the  pain- 
belt  (douleur  en  ceinture),  partial  losses  of  power,  and  other  phenomena, 
which  vary  in  the  two  cases  alluded  to.  Also  in  one  of  them  all  the  singu- 
lar features  which  in  the  early  stages  were  seen  in  the  feet,  were  at  a  later 
stage  exhibited  in  equal  fulness  in  the  hands,  or  rather  in  the  hand,  since 
one  had  been  lost  by  amputation. 

One  other  peculiarity  is  common  to  all  of  them.  They  are  rarely 
amenable  to  treatment.  They  are  aided  for  a  time  by  cold  and  by  rest ; 
but  either  they  remain  unchanged  for  years,  or  else  in  rare  instances 
become  gradually  worse. 

As  to  diagnosis,  I  am  aware  of  no  other  malady  with  which  the  bad 
cases  of  this  trouble  can  be  confounded  ;  but  there  are  certain  other  more 
or  less  painful  affections  of  the  feet,  with  which  the  lighter  forms  might  be 
confused;  and  I  shall,  therefore,  make  some  brief  allusions,  at  the  close  of 
these  pages,  to  the  maladies  of  the  feet,  from  which  it  is  needful  to  distin- 
guish the  disease  I  am  describing. 

Case  I.  The  patient,  a  sailor,  aged  about  forty,  while  in  the  United 
States  naval  service  on  the  coast  of  Africa,  suffered  from  sunstroke.  This 
was  followed  after  a  few  months  by  a  grave  attack  of  coast-fever,  and  from 


20        Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  [July 


this  seemed  to  date  an  enfeebled  condition  of  the  heart,  with  an  apex 
murmur  heard  during  the  systole.  He  reached  the  Norfolk  Hospital  eight 
months  after  his  fever,  and  was  there  during  the  whole  winter.  Some 
time  early  in  the  next  year  he  began  to  have  dull,  heavy  pains,  at  first  in 
the  left,  and  soon  after  in  the  right  foot ;  the  pain  was  a  dull  ache,  and 
seemed  to  be  in  the  interior  of  the  foot,  between  the  sole  and  the  instep. 
At  first,  and  indeed  for  three  months,  the  pain  was  unaccompanied  by  swell- 
ing, but  in  April  this  new  symptom  was  observed,  after  much  exercise, 
and  then  only. 

The  disease  progressed  rapidly,  and  when  I  saw  the  man,  in  June,  his 
condition  was  no  less  strange  than  pitiable.  He  was  a  well-made,  vigorous 
person,  of  rather  ruddy  complexion.  His  appetite  and  digestion  were 
good,  his  bowels  regular,  and  his  urine,  save  some  slight  though  constant 
deposit  of  urates,  in  all  respects  normal.  He  told  me  that  he  had  pain  in 
the  feet  whenever  he  attempted  to  walk,  but  that  while  at  rest  in  bed  he 
was  perfectly  comfortable.  The  case,  as  he  spoke  of  it,  was  to  me  so 
novel  that  I  somewhat  mistrusted  his  statement,  and,  therefore,  directed 
him  to  walk  up  and  down  the  ward  and  about  the  grounds  until  I  sent  for 
him,  which  I  did  when  at  the  close  of  an  hour  my  visit  was  over.  He 
made  his  appearance  in  the  ward,  walking  with  the  step  of  a  man  whose 
feet  were  tender.  On  examining  his  extremities  I  found  them  both 
swollen.  They  scarcely  pitted  on  pressure,  but  were  purple  with  conges- 
tion ;  the  veins  were  everywhere  singularly  enlarged,  and  the  arteries 
were  throbbing  visibly.  The  whole  foot  was  said  to  be  aching  and  burn- 
ing, but  above  the  ankles  there  was  neither  swelling,  pain,  nor  flushing. 
On  other  occasions  I  examined  him  in  bed,  and  then  caused  him  to  stand 
for  a  time.  Almost  at  once,  without  previous  pallor,  the  feet  began  to 
fill  with  blood,  and  after  a  quarter  of  an  hour  or  less,  if  ho  walked,  the 
pain  appeared,  and  with  it  the  swelling  so  increased  as  after  a  time  to 
force  him  to  lie  down.  He  was  very  sure  that  he  had  suffered  pain  long 
before  either  swelling  or  redness  was  observed,  and  I  am  disposed  to  think 
this  statement,  correct.  As  the  autumn  came  on  and  the  weather  grew 
cold,  I  was  able  to  verify  another  of  his  statements,  to  the  effect  that  cold 
relieved  him  and  that  heat  increased  his  sufferings.  In  fact,  he  preferred 
to  wear  slippers  without  stockings,  and  while  on  cool  days  he  could  walk 
for  an  hour  before  his  pain  became  great,  in  warm  weather  a  few  minutes 
of  exertion  were  enough  to  bring  about  this  result.  A  hot  foot-bath  had 
a  like  effect,  and  cold  bathing  was  almost  the  sole  means  of  speedy  relief. 
A  long  series  of  therapeutic  experiments  failed  to  afford  him  any  perma- 
nent ease.  The  local  use  of  cold,  and  of  alternate  heat  and  cold,  band- 
ages, sedative  washes,  lead-water  and  laudanum,  leeching  and  blisters, 
digitalis,  arsenic,  and  tonics,  all  alike  failed  to  help  him,  so  that  at  last, 
having  gained  something  from  the  cold  of  early  winter,  he  left  us.  and  I 
have  never  heard  of  the  issue  of  his  most  singular  history. 

Case  II  G.  K.,  set.  35,  single,  clerk,  American.    The  patient  lost  his 

right  arm  during  the  war,  in  the  year  1862,  and  since  that  time  he  has 
been  gradually  losing  strength.  He  was  not  subjected  to  hard  marching 
when  a  soldier,  and  he  denies  all  venereal  taint. 

The  indirect  cause  of  his  indisposition,  he  thinks,  was  '''army  life,"  and 
the  direct  cause  "prolonged  continence." 

In  1864  he  had  an  attack  of  "typhoid  fever,"  which  left  him  with 
some  impairment  of  vision,  so  that  continued  reading  would  bring  on 
headache. 


1878.]    Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  21 


In  1872  he  was  examined  ophthalmoscopically  by  Liebreich,  wlio  detected 
hypermetropia,  and  gave  him  glasses  for  its  relief.  Some  time  before  this 
latter  date  the  patient  began  to  experience  burning  pain  in  the  soles  of  his 
feet  upon  walking;  if  he  persisted  in  the  attempt  after  this,  the  feet  grew 
red  and  swollen,  and  finally  became  blistered. 

Walking  also  caused  pain  in  the  back.  During  cold  weather  he  was 
moderately  comfortable,  provided  he  did  not  walk ;  but  in  warm  weather 
his  feet  ached  him  nearly  all  the  time,  and  for  relief  he  was  obliged  to  apply 
cold  to  the  feet.  In  this  condition  he  continued,  without  much  change, 
until  August,  187-").  at  which  time  he  made  a  misstep,  and  his  right  ankle 
gave  way  under  him,  and  before  he  recovered  from  the  sprain  a  like  acci- 
dent betel  the  left  ankle. 

A  few  days  later,  while  leaning  on  his  hand,  his  wrist  also  gave  way, 
and  soon  after  this  he  began  to  experience  a  burning  pain  in  the  hand, 
particularly  when  pressure  was  made  upon  the  palm. 

Using  his  hand  also  caused  violent  pain,  after  which  it  became  relaxed 
and  feeble  ;  the  whole  hand  would  then  swell  and  the  fingers  in  particular 
become  red. 

The  pain,  before  mentioned,  in  the  soles  of  his  feet  was  at  first  limited  to 
the  part  immediately  below  the  metatarsophalangeal  articulations,  but  by 
1876  it  began  to  extend  toward  the  outside  of  the  feet,  and  finally  appeared 
upon  the  dorsum  of  the  right  foot.  Pressure  over  this  region  never  caused 
pain,  except  when  the  patient  Avas  suffering  from  a  more  than  usually 
severe  attack.  At  such  times  the  pain  would  shoot  upwards  on  the  outside 
of  the  right  leg.    The  heels  were  never  the  seat  of  pain. 

In  November,  1876,  when  the  foregoing  notes  were  taken,  the  man's 
condition  was  as  follows: — 

The  patient  was  well  nourished,  his  appetite  and  digestion  were  good, 
and  his  bowels  regular.  Walking  caused  so  much  pain  in  the  feet  that  he 
rarely  attempted  it,  but  sat  all  the  time  with  his  feet  elevated,  and  so 
managed  to  keep  moderately  comfortable.  When  in  bed  he  frequently 
left  his  feet  outside  of  the  bedclothes,  in  order  to  keep  them  cool.  After 
a  night's  rest  he  suffered  little,  but  the  pain  reappeared  soon  after  he 
arose.  More  relief  was  obtained  from  cold  applications  than  from  any- 
thing else. 

Standing  upon  his  feet  in  a  very  few  moments  caused  them  to  become 
engorged  with  blood  and  swollen.  This  was  particularly  marked  along 
the  edges  of  the  toes.  This  posture  caused  intense  burning  pain  in  the 
part  of  the  sole  before  mentioned,  but  gave  rise  to  no  pain  in  the  back,  as 
it  did  a  few  years  before.  The  right  foot  was  more  severely  affected  than 
the  left.  Xo  peculiarities  could  be  observed  in  the  stump  of  the  lost  arm, 
and  there  was  no  complaint  of  pain,  either  in  the  stump  or  in  the  lost  arm 
or  hand.  Any  pressure  on  the  left  palm  caused  great  pain  and  local 
flushing,  as  did  any  attempt  to  grasp  an  object ;  but  no  paralysis  of  the 
muscles  of  the  arm  or  hand  could  be  detected.  He  was  able  to  push  with 
his  hand  extended  without  suffering  pain.  There  was  also  excessive 
sweating  of  the  hand.  The  growth  of  the  nails  did  not  seem  to  be  at  all 
affected,  and  this  was  true  also  of  the  toe-nails.  There  were  no  cerebral 
symptoms  other  than  the  headache  after  reading.  There  was  no  tenderness 
over  the  spine,  and  examination  of  the  heart,  lungs,  and  urine  gave  merely 
negative  results.  The  patient  rarely  had  seminal  emissions,  in  fact  only 
about  three  a  year.  The  application  of  the  constant  current  to  the  feet 
where  red,  caused  a  whitening  of  the  part,  which  lasted  longer  than  the 


22 


Mitchell,  Rare  Yaso-motor  Neurosis  of  Extremities.  [July 


whitening  produced  by  simple  pressure.  Massage  was  ordered,  and  at  first 
this  seemed  to  relieve  him,  but  the  improvement  was  transient. 

He  was  ordered  heat  to  the  spine,  galvanism  to  the  feet,  and  digitalis 
and  tincture  of  iron  internally.  After  this  the  patient  was  tost  sight  of 
until  January  31st,  1878,  when  the  remainder  of  these  notes  were  taken, 
lie  was  at  that  time  a  patient  at  the  Elmira  Water  Cure,  New  York. 
The  following  notes,  although  meagre,  were  obtained  with  much  difficulty, 
owing  to  his  condition,  and  to  the  fact  that  his  attendants  knew  but  little, 
if  anything,  of  his  history,  either  before  or  after  his  entrance  into  the 
institution : — 

Patient  entered  the  institution  in  July,  1877,  and  appears  at  that  time 
to  have  been  able  to  walk  a  few  steps  with  the  aid  of  a  crutch;  but  this 
would  almost  immediately  bring  on  an  intense  pain  in  the  soles  of  his  feet, 
in  his  back,  and  in  his  hand.  To  lessen  the  latter  pain  as  much  as  possi- 
ble, he  held  the  crutch  gripped  tightly  between  his  arm  and  side,  and  used 
his  hand  as  little  as  possible. 

His  right  arm  having  been  amputated  near  the  shoulder-joint  made 
progression  very  difficult,  especially  as  the  erect  posture  also  brought  on 
pain  in  his  head,  and  sudden  attacks  of  vertigo. 

In  walking  he  was  noticed  to  drag  his  right  leg  a  little,  but  no  other 
paralysis  was  observed.  In  November  his  disposition  began  to  change, 
and,  instead  of  being  desirous  of  company  and  conversation,  he  became 
morose  and  fond  of  solitude.  His  power  of  conversation  also  left  him,  and 
he  wrould  only  answer  in  monosyllables.  Since  then  he  has  been  confined 
to  bed.  Since  July  he  has  had  seven  convulsions.  In  these  he  became 
rigid,  was  but  slightly  convulsed,  and  did  not  foam  at  the  mouth,  or  bite 
his  tongue.  The  attacks  seemed  to  be  bilateral.  For  several  days  after 
these  seizures  the  patient  would  be  drowsy,  and  during  these  periods 
squinting  would  be  occasionally  noticed. 

He  lies  in  bed,  face  downward,  and  a  little  upon  his  right  side.  This 
position  is  retained  nearly  all  the  time,  as  any  other  causes  pain  in  the 
dorsal  region,  and  in  his  thighs  in  the  line  of  the  sciatic  nerves.  The 
weight  of  the  bedclothes  is  so  distressing  to  him  that  a  hoop  is  needed  to 
keep  them  from  touching  his  back.  He  is  well  nourished,  his  appetite  is 
fair,  and  his  tongue  clean.    He  is,  however,  generally  slightly  constipated. 

His  skin  is  dry  and  cool,  and  there  is  a  branny  desquamation  of  the 
cuticle.  His  conjunctivae  are  congested.  He,  however,  states  that  his 
vision  is  unimpaired,  although  he  wears  powerful  convex  glasses;  there  is 
no  nystagmus;  his  pupils  are  large,  equal,  and  react  readily  to  light.  He 
states  that  his  mouth  is  occasionally  drawn  to  the  right  side,  although  at 
the  time  of  taking  these  notes  it  appears  a  little  drawn  to  the  left.  His 
tongue  is  protruded  in  a  straight  line,  and  without  trembling. 

His  speech  is  hesitating,  whispering,  and  very  slow.  All  questions  are 
answered  with  evident  reluctance,  and  in  monosyllables.  He,  however, 
answers  rationally,  but  the  attempt  apparently  causes  great  effort  and  soon 
exhausts  him.    He  hardly  ever  sleeps. 

There  is  marked  oedema  of  the  body  and  lower  extremities,  and  these 
parts  pit  upon  pressure.  Any  pressure  over  the  dorsal  or  lumbar  region 
of  the  spine,  on  the  outer  part  of  the  thighs  and  on  the  feet,  causes  great 
pain.  Pain  is  also  caused  by  pressure  over  the  scalp,  back  of  the  neck, 
on  the  shoulders,  on  the  hand,  and  on  the  forearm  up  to  the  elbow,  but 
none  is  caused  by  pressure  on  the  upper  arm.  There  is  occasional  spon- 
taneous pain  in  the  stump  of  the  arm,  but  nothing  peculiar  can  be  detected 
on  inspection. 


1878."!    Mitchell,  Rare  Yaso-motor  Neurosis  of  Extremities.  23 


His  hand  is  extremely  cold,  and  the  finger  ends  are  darkly  cyanosed. 
The  fingers  from  the  second  row  of  joints  to  the  tips  are  very  shiny,  and 
the  nails  grow.    He  is  utterly  unable  to  grasp  anything  in  his  hand. 

There  is  spontaneous  pain  in  the  soles  of  the  feet,  particularly  when 
they  are  at  all  warm,  and  pressure  causes  pain  when  made  on  the  soles  or 
on  dorsum  of  the  feet,  but  not  on  the  toes.  There  is  slight  vesication  on 
the  outer  side  of  the  left  foot  and  ankle,  but  this  is  not  the  seat  of  especial 
pain. 

To  the  hand  the  feet  feel  cool,  and  alike  as  regards  temperature,  but  a 
surface  thermometer  held  in  contact  with  the  feet  for  some  time  fails  to 
register  70°  F.,  the  lowest  graduation  on  the  scale.  Under  the  tongue 
the  temperature  is  99^°  F. 

From  the  painful  region  in  the  back  there  is  radiating  pain  around  the 
body,  and  the  patient  states  that  the  sensation  is  that  of  a  "tape  tied 
around"  him.  Cold  applications  to  the  back  relieve  this  pain  considerably, 
and  in  order  that  lie  may  remain  as  comfortable  as  possible  the  tempera- 
ture of  the  room  is  kept  very  low. 

Sensation  appears  to  be  well  preserved  in  the  feet,  and  impressions  are 
properly  located;  the  difference  between  heat  and  cold  is  also  appreciated. 
The  whole  body  except  the  head  is  the  seat  of  a  fine  tremor,  which  is 
much  increased  by  voluntary  motion.  The  muscles  can  be  moved  at  will, 
but  the  eflfort  caused  rapid  exhaustion.  The  right  leg  appears  to  be  a 
little  more  feeble  than  the  left. 

Electro-muscular  contractility  to  the  induced  current  in  the  arm  is  appa- 
rently normal ;  but  no  reaction  is  caused  in  the  legs  to  the  same  current ;  a 
stronger  one  causes  a  general  spasm  of  the  lower  extremities. 

The  patient  never  has  seminal  emissions,  or  priapism.  There  is  occasional 
palpitation  of  heart.  Examination  reveals  feebleness  of  heart's  action,  and 
a  slight  systolic  murmur  heard  best  towards  apex.  The  pulse  is  100  per 
minute.  Examination  of  lungs  gives  negative  result.  Ophthalmoscopic 
examination  reveals  slight  enlargement  of  veins  and  irregularity  of  form  of 
disk,  but  no  choking  in  left  eye.  The  right  disk  appears  whiter  than 
normal.  This  examination,  being  made  with  great  difficulty,  is  therefore 
not  positive. 

The  urine  is  passed  freely  and  in  normal  amount,  it  is  pale,  very  slightly 
acid,  and  upon  standing  deposits  a  light,  floceulent  sediment,  which,  how- 
ever, clears  upon  boiling. 

There  is  no  albumen  either  upon  boiling  or  upon  the  application  of 
Heller's  test,  and  no  casts  could  be  detected  by  the  microscope. 

Case  III  J.  P.  S.,  set.  58,  born  in  Philadelphia,  formerly  a  worker 

in  iron.  The  patient's  family  history  is  unexceptionably  good,  his  an- 
cestors living  to  a  good  old  age,  and  there  is  no  history  of  hereditary 
disease.  With  the  exception  of  an  attack  of  dysentery  twenty-five  years 
ago,  the  patient  has  enjoyed  good  health  until  the  beginning  of  his  present 
indisposition.  He  is  a  temperate  man,  and  denies  all  venereal  taint. 
Thirty-three  years  ago  he  married ;  he  has  had  eight  children,  all  of 
whom  are  alive  and  healthy ;  the  youngest  having  been  born  seventeen 
years  ago.  He  has  been  a  hard  worker,  and  his  business  required  great 
muscular  exercise,  as  he  had  to  use  the  sledge-hammer;  as  a  consequence 
lie  was  compelled  to  stand  nearly  all  the  time.  For  many  years  he  has 
ceased  to  do  manual  labour. 

In  June,  1873,  he  noticed  "  a  burning  sensation"  in  the  extreme  end  of 
both  great  toes  ;  this  came  on  towards  the  close  of  a  hard  day's  work, 


24        Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.    [J uly 


but  soon  disappeared  after  retiring.  Upon  inspection  nothing  was  to  be 
seen  ;  but  the  tissues  seemed  somewhat  indurated  at  the  extremity  of  the 
toes,  and  pressure  at  these  points  caused  pain.  Ordinary  handling  of  the 
foot  gave  rise  to  no  pain  whatever.  These  conditions  lasted  without  change 
for  six  weeks,  and  then  disappeared. 

In  February,  1876,  owing  apparently  to  excessive  exertion  at  the  Cen- 
tennial Exhibition,  and  after  entire  freedom  from  pain  since  1873,  lie  again 
began  to  experience  pain  in  his  great  toes  ;  the  right  one  being  the  most 
painful.  Two  weeks  later,  the  pain  spread  from  the  right  toe  across  the 
sole  beneath  the  metatarsophalangeal  articulations  to  the  right  side  of  the 
foot ;  any  pressure  upon  this  part  was  very  painful,  and  standing  with  his 
shoes  on  became  almost  unbearable.  The  left  toe  in  the  mean  time  caused 
but  little  annoyance.  Rest  in  bed,  as  before,  removed  all  pain.  No 
change  worthy  of  note  occurred  until  the  December  following,  when  the 
pain  in  the  right  foot  became  much  more  severe,  and  he  then  noticed  for 
the  first  time  redness  of  right  foot,  swelling  of  the  veins,  and  slight  oedema 
of  toe;  this  latter  symptom  was  also  present,  but  to  a  less  degree,  in  the  left 
toe. 

By  April,  1877,  the  pain  had  invaded  the  right  heel,  leaving  the  inner 
part  of  the  hollow  of  the  foot  entirely  free.  He  was  now  obliged  to  ele- 
vate his  foot  in  order  to  obtain  any  comfort.  He  describes  the  pain  as 
being  of  an  intense  burning  character,  resembling  the  pain  that  would  be 
caused  by  "  holding  the  foot  very  near  a  red  hot  stove."  Shortly  after 
this  he  began  to  notice  spots  of  discoloration,  each  about  the  size  of  a  pea, 
particularly  towards  the  anterior  part  of  the  right  sole,  where  the  pain  was 
most  intense  ;  by  June  these  spots  were  to  be  found  on  the  right  heel,  and 
a  little  later,  they  appeared  simultaneously  with  the  pain  upon  the  outer 
part  of  the  dorsum  of  the  foot. 

In  the  early  part  of  the  summer  he  began  to  complain  of  vertigo,  flush- 
ing of  the  face,  injection  of  the  conjunctiva'  and  tinnitus  aurium  ;  tlx'  latter 
symptom  being  very  annoying,  and  resembling  a  steam  whistle.  In  addi- 
tion to  these  symptoms  he  began  to  suffer  from  amnesia  ;  he  had  great  diffi- 
culty in  selecting  the  proper  words  to  express  his  thoughts,  would  make 
many  blunders,  and  would  be  aware  of  them  as  soon  as  made.  There  was 
also  some  loss  of  control  over  the  movements  of  the  tongue.  The  amnesia 
lasted  but  one  week,  while  the  other  symptoms  continued  for  about  two 
months. 

Shortly  after  the  amnesia  (in  the  latter  part  of  July)  he  had  paresis  of 
the  right  arm  and  leg ;  this  lasted  one  week,  was  not  accompanied  by  pain 
or  formication,  and  the  patient  does  not  remember  any  accompanying  facial 
palsy,  nor  was  there  any  loss  of  control  over  the  sphincters. 

In  August  he  had  a  violent  attack  of  dysentery,  while  at  Atlantic  City, 
Avhere  lie  had  gone  to  recuperate.  This  attack  lasted  three  weeks,  and 
during  that  time  he  was  entirely  free  from  pain  in  the  feet. 

In  October  the  pain  became  worse  at  night.  He  then  had  the  in- 
duced current  applied,  by  an  electropath,  every  day  for  six  weeks,  for  two 
hours  a  day  ;  the  poles  being  passed  all  over  the  body.  At  first  this  gave 
liim  relief  for  about  three  or  four  hours  each  night ;  but  at  the  end  of  five 
weeks'  treatment  the  pain,  which  previous  to  this  time  had  been  confined 
to  the  left  toe,  began  to  spread  across  the  sole  beneath  the  metatarso-pha- 
langeal  articulation  with  the  little  toe,  and  it  then  became  terribly  severe. 
When  lie  wished  to  move  about  his  room,  he  was  now  compelled  to  do  so 
on  his  hands  and  knees,  whereas  before  he  was  able  to  get  about  with  the 
aid  of  a  crutch  and  cane. 


1 878.]    Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities. 


25 


By  the  7th  of  December  an  aching  pain,  like  that  of  a  cold,  became 
general  over  his  whole  body,  and  remained  for  ten  days.  About  this  time 
he  began  to  notice  slight  loss  of  control  over  his  bladder. 

Cod-liver  oil  and  daily  massage  were  now  ordered,  and  almost  immedi- 
ately the  pain  began  to  diminish,  and  in  three  days  it  had  entirely  left  the 
left  foot. 

One  application  of  the  constant  current  (fourteen  cells  descending  cur- 
rent) on  December  31st  caused  little  if  any  sensation  at  the  time,  but  in  a 
few  hours  the  pain  became  much  more  severe,  and  extended  up  the  right 
leg  to  the  hip  ;  it  also  returned  to  the  left  foot.  This  exacerbation  lasted 
three  days;  the  pain  then  entirely  left  the  left  foot,  and  since  that  time  he 
lias  been  gradually  improving.  At  different  times  there  has  been  slight 
jerking  of  the  right  leg,  particularly  when  the  pain  has  been  severe. 


I  first  saw  this  man  in  December,  1877,  in  consultation  with  Prof.  Wm. 
H.  Pancoast.  His  condition  at  the  time  was  as  follows :  Patient  is  a  spare 
man,  but  is  fairly  nourished,  his  appetite  is  fair,  and  his  bowels  perfectly 
regular.  Pain  exists  in  the  feet  over  the  areas  delineated  (see  diagrams), 
particularly  when  the  foot  is  dependent ;  pressure  causes  great  pain  over 
this  region,  and  standing  upon  the  foot  is  almost  insupportable. 

Inspection  shows  slight  redness  of  the  right  foot,  and  a  few  dark  spots, 
about  the  fourth  of  an  inch  in  diameter  each,  situated  mostly  towards  the 
anterior  part  of  the  sole.    There  is  also  dwindling  of  the  right  leg. 

The  left  ankle,  calf,  and  thigh  at  middle  third  measure  respectively 
7,  11,  and  16^  inches;  while  at  the  corresponding  points  the  right  leg 
measures  6^-,  9|,  and  15^  inches  only,  and  there  is  distinct  appearance  of 
atrophy  with  remarkable  flabbiness  of  the  muscles.  Lowering  the  right  foot 
almost  instantly  causes  very  marked  distension  of  the  superficial  veins,  and 
intense  flushing  of  the  skin,  and  this  procedure,  as  before  mentioned,  gives 
rise  to  acute  pain.  The  temperature  of  the  right  foot  is  decidedly  higher 
than  that  of  the  left. 

Sensation  is  normal  over  the  left  foot,  but  there  appears  to  be  some  hy- 
peresthesia, even  to  light  touches  over  the  right  sole,  an  ''indescribable 


Fig.  1. 


Fig.  2. 


Area  of  pain  in  right  foot,  June  to  December,  1S77. 


Fig.  3. 


2(5        Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  [July 

sensation"  being  caused  by  touching  the  discoloured  spots  with  a  sharp 
point.  The  sensation  over  the  rest  of  the  foot  and  leg  appears  normal. 
Appreciation  of  warmth  and  cold  seems  perfect  in  both  feet. 

The  electro-muscular  contractility  appears  normal  in  the  left  leg  and  foot, 
while  in  the  right  it  appears  to  be  distinctly  increased  despite  the  wast- 
ing. There  is  no  facial  palsy,  and  the  tongue  is  protruded  in  a  straight  line. 
The  grip  of  the  right  hand  is  strong,  a  little  more  so  than  the  left5;  there 
is  no  apparent  wasting,  and  the  sensation  is  good.  There  is  no  pain  in 
any  spinal  region,  and  the  patient  is  able  to  stand  perfectly  steady  with  his 

eyes  closed  for  a  short  time,  but  then  un- 
steadiness is  caused  by  the  intense  pain. 

I  saw  this  patient  about  two  weeks  later, 
and  found  him  in  bed,  with  the  bed-clothes 
lifted  off  his  feet  by  the  aid  of  a  cage  of 
half  hoops.  The  congested  look  of  the  pain 
areas  in  the  sole  was  remarkable.  They 
looked  like  severe  frost-bites.  The  sudden 
increase  of  pain  and  filling  of  the  vessels 
on  his  assuming  the  erect  posture  were  as 
notable  as  ever,  and  the  rapid  whitening, 
when  the  legs  were  lifted,  seemed  to  me  no 
less  interesting.  Pressure  on  the  right 
sciatic  nerve  suddenly  increases  the  sense 
of  burning.  As  he  was  notably  thin  and 
pale,  it  was  agreed  that  he  should  continue 
/■  ~  to  take  dialyzed  iron  and  cod  oil,  and  that 

C~    /'  massage  should  be  used  daily,  as  before,  on 

the  feet  and  legs.  He  was  also  dry-cupped 
over  the  spine. 

The  amendment  under  this  treatment  was  almost  sudden,  and  lias  con- 
tinued. To-day,  Feb.  17,  1878,  he  came  to  see  me,  and  said  lie  was 
better  than  he  had  been  for  a  year.  It  is  to  be  remembered,  however,  that 
he  has  once  before  improved,  and  again  relapsed.  He  tells  me  that  the 
wasted  right  leg  is  enlarging,  and  certainly  his  gain  in  flesh  and  colour 
was  satisfactory. 

Dr.  Morris  J.  Lewis,  to  whose  care  I  am  indebted  for  the  notes  of  this  ca^e. 
endeavoured,  on  Feb.  16,  to  study  his  temperatures;  unfortunately  for  this 
purpose  he  was  already  better.  However,  I  give  the  result.  Dr.  Lewis 
says  :  "  I  held  the  thermometer  carefully  in  position,  each  time  I  made  an 
observation,  for  over  fifteen  minutes.  When  the  patient  was  on  his  back  in 
bed  the  temperature  of  the  right  sole  was  96|°,  the  left  sole  was  cold  and 
clammy,  and  would  not  register  93°,  the  lowest  degree  on  the  thermometer  ; 
it  was  held  in  position  twenty  minutes.  When  the  right  foot  was  on  the 
floor  the  mercury  rose  only  to  95-|°,  and  then  began  to  fall  again,  and  the 
foot  began  to  lose  some  of  the  congestion,  which  came  on  immediately 
after  placing  it  on  the  floor. 

"  On  the  dorsum  of  the  right  foot  when  dependent  the  mercury  stood  at 
95  J °.    The  left  foot  was  still  too  cold  for  my  thermometer  to  register." 

The  group  of  cases  which  I  have  just  described  seem  to  me  to  be  closely 
related,  and  to  differ  chiefly  in  degree,  and  in  the  fact  that  one  of  them  was 
arrested  in  its  pathological  progress  ;  whether  or  not  I  am  correct  in  sus- 
pecting that  they  may  represent  stages  of  one  malady  can  only  be  deter- 


Area  of  pain  in  left  foot,  Oct.  1S77. 


1878.]    Mitchell,  Bare  Vasomotor  Neurosis  of  Extremities.  27 


mined  by  future  research  ;  but.  with  this  word  of  caution  and  reserve,  there 
can  be  no  harm  in  calling"  attention  to  them  as  members  of  one  genus. 

I  believe  that  the  group  of  cases  described,  together  with  some  of  those 
which  I  shall  now  add,  represent  an  unrecognized  type  of  spinal  or  cerebro- 
spinal disorder,  and  that  they  may  be  found  in  the  future  to  be  associated  with 
distinct  lesions  of  definite  regions.  The  mere  fact  of  pain,  with  vaso-motor 
disturbances,  docs  not,  I  think,  as  yet  authorize  me  to  attempt  to  localize 
the  malady,  and  I  prefer  to  resist  the  temptation  to  speculate  in  this  direc- 
tion without  sufficient  grounds. 

The  gravest  case  of  the  series  has  a  good  deal  the  aspect  of  a  sclerotic 
affection  ;  but,  as  to  the  others,  this  would  seem  less  probable  if  they  stood 
alone. 

In  all  of  the  examples  the  pain  seems  to  have  preceded  the  vaso-motor 
phenomena,  so  that  we  must  look  upon  the  latter  either  as  caused  by  the 
implication  of  vaso-motor  centres,  or  as  due  to  a  reflex  affection  caused  by 
the  pain  or  by  the  disorder  of  the  central  organs,  disease  of  which  gave 
rise  to  pain.  It  is  to  be  noted  that  in  these  cases  pain  came  before  flush- 
ing was  habitual,  and  that  afterwards  it  always  arose  whenever  the  part 
was  so  situated  as  to  give  rise  to  flushing;  while  in  Sir  James  Paget's 
case,  which  I  shall  presently  relate,  the  pain  was  coincident  with  intense 
pallor  of  the  limbs. 

The  following  case  is  remarkable,  because  of  being  confined  to  the 
hands,  and  because  of  its  irregular  intermittent  nature : — 

Case  IV  Mr.  S.,  an.  20,  merchant.  Had  syphilis  with  slig'ht  secon- 
dary symptoms  in  18G7  ;  was  treated  with  mercury  and  iodides,  and  has 
had  no  return  of  the  troubles.  His  father  died  of  tubercular  disease.  In 
1875  he  had  a  slight  attack  of  rheumatic  fever,  but  made  a  good  and  rapid 
recovery.  Three  months  later  he  noticed  that  in  using  a  pen  the  ball  of 
the  thumb  became  sore,  and  soon  after  he  observed  a  like  soreness  of  the 
palm  after  driving  some  nails  into  a  wall.  Shortly  after,  without  known 
cause,  he  was  attacked  with  a  sharp  burning  pain  in  the  cushions  of  all  of 
the  fingers  of  the  left  hand  ;  this  lasted  but  a  few  days.  Then  he  had  a 
severe  attack  in  the  right  hand,  on  the  thenar  eminence,  and  from  this 
time  the  pain  was  rarely  absent  for  a  day. 

He  consulted  me  a  few  months  afterwards,  when  I  found  him  in  the 
following  state  :  He  was  ruddy  and  well  nourished,  had  no  dyspepsia  and 
no  disorder  of  any  viscus.  Both  hands  were  suffering  from  acute  burning 
pain,  which  affected  limited  regions,  and  varied  in  its  place  and  in  severity. 
When  I  first  saw  him  the  finger  ends  were  darkly  congested,  and  over 
the  thenar  and  hypothenar  eminences  of  the  left  hand  and  on  the  latter 
part  only  in  the  right  hand  were  distinctly  limited  patches  of  dusky  red- 
ness, sometimes  mottled.  In  the  affected  parts  the  pain  was  burning  and 
aching  in  character,  and  was  made  worse  by  the  least  pressure,  which  wras 
also  competent  to  bring  on  pain  at  once  or  to  increase  it ;  and  when  I 
pressed  with  my  thumb  on  the  palm,  which  was  free  from  pain  at  the  time, 
a  limited  well-defined  area  of  congestion  appeared,  accompanied  with  in- 
tense burning.  The  nerves  of  the  arms  were  not  unusually  sensitive,  and 
the  temperature  of  the  burning  parts  was  but  a  trifle  above  that  of  the 


28        Mi  tchell,  Rare  "Yaso-motor  Neurosis  of  Extremities.  £July 


rest  of  the  member.  The  next  day  he  appeared  again  to  show  me  that  he 
had  no  pain  ;  but  he  carried  his  arms  curiously,  holding  the  hands  across 
his  breast,  and  assuring  me  that  to  walk  with  them  swinging  at  his  side 
would  renew  the  pain.  When,  at  my  request,  he  allowed  one  to  hang 
down,  it  became  flushed  all  over  in  a  few  minutes,  and  then  grew  paler 
until  there  remained  several  large  islets  of  dusky  redness,  which  only  after 
a  few  minutes  became  painful.  Next  he  rested  his  body  on  the  other  hand 
placed  on  a  table.  The  same  changes  occurred  at  once,  and  the  pain  be- 
came intense,  the  finger  ends  especially  burning  and  throbbing,  and  pre- 
senting a  smooth  dusky  red  appearance.  Heat  made  him  worse,  and  he 
looked  forward  to  the  summer  witli  apprehension,  since  each  return  of 
warm  weather  had  made  him  suffer,  while  the  cold  of  winter  had  always 
proved  grateful.  Long  immersion  in  cool,  not  ice-cold,  water  greatly 
eased  him.  and  at  times  even  put  an  end  to  his  pain. 

He  had  no  headache  or  vertigo,  but  at  the  third  cervical  vertebra  there 
was  a  dull  pain  when  he  made  any  extreme  movements  of  the  head  and 
neck.  At  times  he  had  numbness  of  the  hands,  and  this  was  very  common 
at  night,  but  I  could  not  find  that  the  sense  of  touch  was  lessened,  although 
of  this  I  was  not  secure,  because  the  least  pressure  with  the  compass  points 
caused  pain  and  congestion.  With  the  attacks  came  always  great  increase 
of  perspiration.  Of  course,  this  singular  malady  made  his  life  one  long 
torment,  and,  as  an  example  of  the  annoyances  to  which  he  was  subject, 
I  may  say  that  he  was  forced  to  immerse  his  hands  in  cold  water  when  he 
wished  to  cut  his  nails.  He  thought  that  there  was  at  times  slight  burning 
in  the  feet,  but  they  showed  no  signs  of  congestion,  and,  as  he  could  walk 
for  miles  in  all  weather,  I  am  inclined  to  think  that  he  was  mistaken. 
After  much  local  and  general  treatment,  antisyphilitic  and  other,  he  was 
greatly  eased  by  a  succession  of  large  blisters  on  his  neck.  He  went  to 
Europe  soon  after,  and  I  lost  sight  of  him  for  a  long  time.  I  have  Bince 
learned  that  the  pain  lessened,  but  that  having  found  that  stimulants  in 
large  amount  eased  it,  he  had  become  an  habitual  drinker,  and  was  in 
utterly  broken  health.  I  cannot  say  whether  or  not  he  retained  the  burn- 
ing pain. 

I  may  add  that,  when  at  his  best,  movement  of  the  wrist  and  fingers 
gave  rise  to  no  pain,  and  that  the  torment  seemed  to  be  in  the  subcuticular 
tissues,  and  not  on  the  surface  of  the  skin. 

It  is  needless  to  point  out  the  close  analogy  between  this  ease  and 
those  which  I  have  reported,  and  in  which,  save  in  one,  the  pain  was  eon- 
fined  to  the  feet. 

Case  V  I  was  consulted,  three  years  ago,  as  to  a  case  somewhat  simi- 
lar to  that  of  Mr.  S.,  but  have  mislaid  the  notes  of  it,  so  that  I  shall  con- 
tent myself  with  stating  that  it  followed,  in  this  instance,  a  nearly  mortal 
attack  of  remittent  fever,  and  seemed  directly  due  to  the  long  use  of  a 
small  hammer,  used  in  breaking  rocks  for  geological  stud}',  at  least  it  was 
to  this  that  the  patient  referred  his  disorder.  In  most  other  respects,  the 
cases  were  similar,  but  in  the  latter  example,  the  blotches  were  larger,  and 
the  attacks  lasted  for  weeks  at  a  time.  There  was  in  this  case  a  certain 
stiffness  of  the  neck,  and  at  times  slight  unsteadiness,  but  no  true  vertigo, 
and  no  ear  or  eye  symptoms.  The  attacks  could  be  made  worse  by  pres- 
sure, and  could  be  brought  on  by  it.  The  burning  pain  was  intense,  and 
when  the  attacks  went  off  there  was  often  for  some  hours  a  notable  pallor 
and  cold  of  the  hands. 


1878.]    Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  29 

While  this  paper  was  passing  through  the  press,  Professor  Alfred  Stille 
placed  at  my  disposal  the  following  notes  of  a  case  reported  by  his  son, 
Dr.  Henry  L.  Stille,  living  at  Guerrero,  Mexico.  It  is  so  interesting, 
from  the  combination  of  livid  extremities,  burning  pain,  and  trophic 
changes,  that  I  regret  not  to  have  a  fuller  detail  of  symptoms. 

Case  YI. — The  patient  is  a  woman  29  years  old.  She  has  a  dark  com- 
plexion, and  is  well  developed  and  nourished.  There  is  no  history  of 
hereditary  disease  ;  neither  phthisis,  scrofula,  nor  syphilis.  There  is  no 
disease  of  the  heart  or  lungs.  All  the  natural  functions  are  well  performed, 
except  menstruation,  which  is  at  times  profuse  and  at  others  scanty,  and 
always  accompanied  by  severe  pain. 

Three  years  ago,  while  menstruating,  she  fell  into  the  river ;  the  day 
following  the  menses  stopped,  and  did  not  reappear  for  several  months. 
.V  week  after  the  cessation,  she  noticed  a  peculiar  tingling  or  burning  on 
the  palmar  surface  of  both  hands,  from  the  second  phalanx  to  the  tips. 
This  continued  until  it  involved  also  the  dorsal  surface  of  the  same  por- 
tion of  the  fingers.  About  the  time  of  the  expected  return  of  her  menses, 
she  had  intermitting  flushes  of  heat  over  the  whole  face  except  the  fore- 
head, and  the  extremities  of  the  fingers  were  observed  to  be  of  a  livid 
color  and  hyperaisthetic.  These  symptoms  now  exist,  and,  besides,  the 
fingers  are  clubbed,  the  nails  four  or  five  times  their  natural  thickness,  and 
curving  over  the  tips  of  the  fingers.  It  seems  as  if  the  muscular  and  fatty 
portions  had  shrunken,  and  also  as  if  the  last  phalanges  had  been  absorbed. 
The  color  of  the  skin  over  the  affected  parts  is  bluish,  and  the  want  of 
power  in  the  fingers  makes  it  impossible  for  the  woman  to  sew  or  work  at 
all,  while  the  tingling  and  burning  are  constant,  but  increased  at  each 
menstrual  period,  when  they  are  also  felt  in  the  face.  There  is  no  fever 
nor  headache,  and  the  patient  eats  and  sleeps  well.  A  vaginal  and  uterine 
examination  gives  only  negative  results. 

Cases  precisely  like  those  I  have  described  must  be  singularly  rare,  but 
I  have  found  a  few  which  present  enough  likeness  to  make  me  willing  to 
((note  them  as  belonging  clinically  to  a  group  which  needs  a  larger  study. 
In  the  following  case  there  were  burning  pain,  great  congestion,  some 
hardening  of  the  areolar  tissues,  and  swelling. 

Case  YH.—G.  P.,  a?t.  22,  baker,1  had  gonorrhoea  in  1854.  In  1856,  he  had 
a  chancre,  and  in  three  months  cutaneous  secondary  accidents  and  rheumatism. 
He  recovered  rapidly.  In  Oct.  1858,  after  excessive  labour,  he  felt  in  the  toes  and 
fingers  acute  pains,  with  swelling,  heat,  and  redness.  He  had  a  pulse  of  72,  and 
no  lesions  of  any  viscus.  The  heat  and  swelling  and  pain  were  intolerable,  and 
were  eased  only  in  very  cold  water,  or  by  exposure  to  a  temperature  a  little 
above  zero  of  C.  Somewhat  later,  rare  pustules  formed  on  the  hands,  and  the 
agony  seems  to  have  been  excessive.  Nothing  is  said  as  to  pressure,,  or  touch 
being  painful,  except  that  at  last  the  upright  posture  became  unbearable.  This 
disease  lasted  about  two  months,  when  the  symptoms  lessened  in  severity,  while 
the  loss  of  muscular  power  became  notable,  especially  in  the  extensors  of  the  feet. 
At  the  same  time,  the  sensibility  of  the  feet  became  so  much  affected,  that  he 
could  not  feel  the  ground.    The  patient  recovered  within  three  months. 

The  case  I  have  quoted  briefly  is  a  fair  example  of  a  few  others  to  be 
found  in  French  medical  literature.    They  are  usually  described  as  cases 

1  Le  Bordeaux  Medical,  Sept.  23,  1873.    M.  Greiner. 


30        Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  [July 


of  sporadic  acrodynia,  owing  to  their  marked  resemblance  to  the  malady 
which  appeared  as  an  epidemic  in  France,  in  1828,  1829,  and  1830  (a%pea 
extremities — o&vvq — pain,  acrodynia).  It  has  since  been  seen  so  rarely, 
that  the  few  cases  described,  and  which  seem  to  have  lacked  many  of  the 
symptoms  of  the  original  disease,  may  really  have  been  due  to  other  causes 
than  those  which  gave  birth  to  it. 

The  epidemic  belonged  chiefly  to  the  summer  months,  and  was  char- 
acterized by  vomiting  and  diarrhoea,  oedema  of  the  limbs,  redness,  or  dark 
splotches  like  frost-bites  on  the  feet  and  hands,  some  thickening  of  the 
skin,  intense  pain,  sense  of  heat,  dysesthesia  of  palms  and  soles.  The 
pain  existed  if  the  congestion  was  absent.  There  were  cramps,  local 
spasms,  and  sometimes  loss  of  power.  Relapses  were  frequent,  and  death 
was  very  rare.  The  attacks  lasted  from  a  few  days  to  two  months.  I 
have  mentioned  this  disease  merely  to  distinguish  it  from  the  chronic 
malady  I  have  described,  but  the  analogies  are  no  less  striking  than  the 
differences. 

The  cases  which  follow  are  members  of  the  group  I  have  already  de- 
scribed and  illustrated,  but  differ  in  being  milder.  Perhaps,  were  they 
more  fully  reported,  the  resemblance  might  be  yet  more  striking. 

Vulpian,1  after  discussing  the  local  asphyxia  of  Raynaud,  describes,  with 
exasperating  brevity,  a  case  which  he  saw  with  Alph.  Guerin  : — 

Case  VIII. — The  patient,  a  nervous  woman.  35  to  40  years  old.  had  been 
tormented  for  more  than  a  year  by  attacks  of  painful  burning  of  all  four  members, 
but  especially  of  the  legs  and  feet.  This  trouble  broke  out  nearly  every  day,  but 
at  no  regular  hour.  When  it  began,  the  feet  and  lower  part  of  the  legs  became 
congested,  the  skin  grew  dark-red  and  very  warm,  while  the  arteries  of  the  feet, 
which  in  the  interval  were  scarcely  to  be  felt,  beat  with  violence,  and  appeared 
to  be  dilated.  There  seemed  t  o  be  at  the  same  time  a  very  painful  sense  of  numb- 
ness, and  to  walk  so  increased  the  symptoms  that  exercise  afoot  became  impos- 
sible. The  only  relief  was  found  in  cold  foot-baths.  Many  means  of  relief  were 
used,  but  bromides,  ergot,  galvanism,  and  a  number  of  other  remedies  all  alike 
failed  to  be  of  service.  M.  Vulpian  adds  that  the  congestion  came  on  without 
precedent  anaemia. 

M.  Sigerson,2  whom  Vulpian  also  quotes,  has  published  a  somewhat 
similar  observation,  in  which  there  was  feebleness  of  the  four  members, 
with  congestion,  heat,  and  sensitiveness  of  the  hands.  Heat  made  the 
disorder  wrorse  ;  cold  relieved  it. 

The  following  case,  which  I  quote  somewhat  in  full,  appears  to  have 
been  a  good  but  irregular  example  of  the  disorder,  illustrated  by  my  own 
cases,  and  is  valuable  because  it  comes  from  the  pen  of  so  acute  an  ob- 
server as  Dr.  Graves.3 

Case  IX. — A  young  lady,  aged  16,  having  had  poor  health  for  some  time 
previously,  then  suppressed  catamenia,  followed  by  a  severe  diarrhoea,  which 
weakened  her  greatly,  was  attacked  by  paroxysms  of  heat  and  tingling  of  the  sole 
of  the  foot,  then  of  the  instep,  ankle,  and  leg  to  the  middle  of  the  calf ;  subsiding 
on  one  side  and  then  beginning  on  the  other,  the  sensation  of  heat  becoming 


1  L'Appareil  Vaso-moteur,  t.  ii.  p.  623. 
3  Clin.  Lect.,  ed.  1864,  p.  826. 


2  Progres  Medical,  1S74. 


1878.]    Mitchell,  Bare  Vasomotor  Neurosis  of  Extremities.  31 


extreme,  and  the  accompanying  pain  almost  unbearable.  As  these  symptoms 
increased,  the  vascular  congestion  and  fulness  of  the  limb  augmented,  and  all  the 
vessels  became  prominent.  The  attacks  lasted  eight  or  nine  hours,  leaving  her 
with  a  sense  of  uneasiness  in  the  limbs,  and  some  numbness  or  ill-defined  morbid 
sensations.    The  daily  amount  of  ease  did  not  exceed  three  hours. 

The  congestion  of  the  cutaneous  capillaries  caused  the  skin  to  groAv  red,  then 
the  hue  deepened  ;  it  became  swollen,  smooth,  and  shining — the  colour  of  a  black 
cherry  when  nearly  ripe — and  exquisitely  sensitive  to  touch.  When  the  hot  fit 
ceased,  these  phenomena  slowly  disappeared,  the  part  gradually  becoming  pale, 
deadly  cold,  and  comparatively  free  from  pain.  Then  the  same  phenomena  ap- 
peared in  the  other  foot  and  leg. 

The  attacks  began  daily  at  seven  in  the  morning,  and  lasted  until  four  in  the 
following  morning  ;  during  this  time  she  was  unable  to  sleep.  She  was  obliged 
to  sit  or  recline  during  the  entire  day,  since,  if  she  walked,  the  pain  and  heat  were 
immediately  brought  on. 

The  catamenia  had  been  restored  after  six  months,  and  her  general  health 
seemed  good,  considering  the  almost  incessant  pain  and  loss  of  sleep. 

All  these  phenomena  increased  in  severity,  so  that  one  year  later  the  limbs 
were  constantly  swollen,  and,  whether  cold  or  hot,  equally  painful.  Both  the 
hot  and  cold  stages  were  attended  with  acute  pain  and  extreme  discoloration. 
Applications  of  cold  water  aloe.e  gave  any  relief. 

Three  months  later  a  tendency  to  palpitation  came  on  without  cause,  and  with 
it  a  similar  feeling  of  pulsation  in  the  legs.  Also  some  constipation  ;  easily  re- 
lieved by  magnesia  ;  but  the  movements  of  the  bowels  so  induced  caused  slight 
faintness.  The  urine  was  scanty,  reddish,  and  muddy  ;  the  sediment,  white  or 
reddish. 

Driving  caused  pain  in  the  left  side  ;  headaches  became  frequent,  and  the  com- 
plexion varied.  The  disease  of  the  feet,  however,  was  not  accompanied  by  the 
least  derangement  of  the  general  circulation,  or  of  the  state  of  the  rest  of  the  skin. 

Three  years  from  the  commencement  of  the  affection  the  intermissions  lasted 
from  11  A.  M.  to  7  P.  M.,  and  more  rest  Avas  secured. 

"It  is  curious  that  this  long-continued  derangement  in  the  circulation  of  her 
lower  extremities,  and  the  extraordinary  pain  the  patient  experienced  daily  for 
six  years,  have  not  produced  any  paralysis,  any  diminution  of  muscular  power, 
thickening  of  the  skin,  induration  of  the  subcutaneous  areolar  tissue,  or  stiffness 
of  the  joints.  Considering  how  hot,  red,  and  swollen  a  considerable  portion  of 
each  limb  is  during  many  hours  every  day,  it  is  quite  surprising  that  no  evident 
alteration  of  structure  was  the  result.  This  fact  is  extremely  interesting  in  a 
physiological  and  pathological  point  of  view,  proving,  as  it  undoubtedly  does, 
that  changes  in  texture  are  influenced  by  causes  quite  independent  of  the  state  of 
the  local  circulation." 

"Although  nearly  every  remedy  in  the  Pharmacopoeia  was  tried,  none  seemed  to 
have  the  least  effect;  and  she  gradually  got  well,  it  might  be  said,  in  spite  of 
medicine." 

Case  X. — Mrs.   ,  aged  82,  of  a  robust  and  healthy  constitution,  florid 

complexion,  in  February,  1839,  had  a  slight  paralytic  affection  of  the  left  arm 
and  leg,  preceded  and  accompanied  by  headache,  vertigo,  flashes  of  light  before 
the  eyes,  etc.  About  one  month  later  she  experienced  a  sensation  of  cold  in  the 
right  foot,  which,  on  rubbing  the  part,  gave  place  to  a  feeling  of  heat  and  itch- 
ing. On  examination,  she  found  that  the  anterior  half  of  the  foot  was  swollen 
and  red.  In  about  three  weeks  from  the  first  seizure,  the  sensation  of  cold  con- 
tinuing, it  became  extremely  painful,  and  she  then  applied  for  medical  advice. 

Aug.  1839.  Complains  of  severe  pain  in  anterior  part  of  right  foot,  wdiich  is 
swollen  and  red  ;  there  is  considerable  oedema  of  the  ankle  and  lower  part  of  the 
leg;  the  extremities  of  the  toes  are  dark  red,  with  some  lividity.  Her  general 
health  is  good,  with  the  exception  of  occasional  headache  with  vertigo.  Bowels 
free  ;  appetite  good  ;  pulse  regular. 

Liniment  and  leeches  gave  some  relief. 

Two  weeks  later,  as  the  pain,  redness,  and  swelling  exhibited  exacerbations, 
recurring  every  second  day,  quinine  was  tried  in  various  ways  without  benefit. 
The  pain  was  now  of  a  most  excruciating  character.     Sometimes  one  toe,  and 


32        Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  [July 


sometimes  two  or  more  were  simultaneously  attacked  ;  and  in  proportion  to  the 
intensity  of  the  pain,  the  affected  parts  became  swollen,  red,  and  then  of  a 
shining  purple  hue. 

She  was  then  ordered  twenty  minims  of  the  wine  of  colchicum  root  three  times 
daily,  in  an  ounce  of  camphor  mixture  ;  and  a  poultice  was  applied  containing 
one-half  ounce  of  extract  of  hemlock,  and  ten  grains  of  watery  extract  of  opium, 
with  one  pint  of  decoction  of  white  poppy.  This  gave  great  relief,  and  in  two 
weeks  the  foot  had  almost  assumed  its  natural  appearance.  The  pain  became  of 
a  different  character,  and  resembled  the  sensation  called  "asleep;"  and  former 
applications  became  intolerable — even  the  hemlock  poultices. 

Two  months  and  a  half  later  the  foot  had  lost  all  pain  and  assumed  a  natural 
appearance. 

About  one  month  later  she  had  another  stroke,  and  soon  died. 

"  It  is  obvious  that  the  good  effect  of  the  colchicum  may  excite  suspicion  that 
the  inflammation  was  of  a  gouty  nature  ;  still,  however,  the  manner  in  which  it 
so  gradually  began,  the  remarkable  violence  of  the  pain,  and  the  change  of  colour 
in  the  skin  which  accompanied  each  paroxysm,  were  of  so  striking  a  character, 
and  presented  analogies  with  the  case  of  the  young  lady  before  related  so  obvious, 
that  the  histories  are  placed  side  by  side. 

"The  absence  of  dyspepsia,  and  all  constitutional  or  local  symptoms  of  gout, 
up  to  the  age  of  eighty-two ;  the  freedom  from  gouty  deposits,  which  the  urine 
exhibited  throughout  the  whole  course  of  the  old  lady's  malady  ;  and  various 
circumstances  that  cannot  have  escaped  your  notice,  render  the  hypothesis  which 
ascribed  her  suffering  to  gout  more  than  doubtful,  and  the.  doubt  is  still  further 
increased  by  the  very  gradual  manner  in  which  the  disease  subsided  under  the 
use  of  colchicum,  and  its  preserving  the  '  tertian'  character  to  the  end." 

The  pain  of  the  foot  and  toes  was  so  great,  and  the  discoloration  and  purple 
hue  of  the  skin  so  intense  that  senile  gangrene  was  apprehended. 

Sir  James  Paget  lias  described  a  case  which  somewhat  resembles  these, 
and  is  a  remarkable  illustration  of  vaso-motor  disturbances.  I  do  not 
speak  of  it  as  precisely  like  my  own  or  Graves'  eases. 

Case  XI. — The  patient,  a  young  man,  desirous  of  "hardening"  himself, 
stood  in  cold  water  up  to  his  knees  for  eight  mornings,  and  endured  at  the  same 
time  a  cold  shower-bath.  These  brought  on  disturbances  in  the  blood-supply  to 
his  feet,  so  that  walking  caused  them  to  become  cold,  white  and  numb,  and  aching 
when  he  ceased  walking ;  they  pretty  rapidly  flushed,  growing  ruddy  and  hot, 
with  over-filling  of  the  veins  while  the  pain  subsided. 

It  is  curious  that  in  the  cases  I  have  given,  or  quoted,  exercise  caused 
the  feet  to  flush  and  grow  painful,  while  in  this  one,  exertion  afoot  pro- 
duced contraction  of  the  vessels,  with  pain,  and  rest  after  exercise  brought 
about  flushing. 

Exercise  naturally  increases  the  flow  of  blood  to  a  part,  and  in  the  cases 
I  have  reported  there  seems  to  have  been  an  exaggeration  of  this  natural 
result,  and  more  rarely,  and  only  in  some  cases,  a  contraction  of  the  vessels, 
as  though  the  controlling  centres  were  sometimes  in  a  paretic,  and  some- 
times in  an  excitable  state.  It  is,  however,  unwise  to  speculate  physio- 
logically until  we  are  in  possession  of  a  far  larger  number  of  these 
interesting  cases. 

I  shall  therefore  content  myself  with  calling  attention  briefly  to  some 
other  forms  of  painful  feet  with  which  the  present  disorder  may  be  con- 
founded, and  I  do  this  the  more  readily,  because  I  myself  have,  I  fear, 
confounded  two  distinct  maladies  in  my  former  paper. 


1878.]    Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  33 


The  disorder  for  which  this  one  might  most  readily  be  mistaken  M  as 
briefly  mentioned  by  Prof.  Gross  in  his  "  Surgery"  as  podynia,  and  was 
described  by  him  as  a  disease  peculiar  to  tailors.  In  my  own  paper 
{Phila.  Med.  Times)  I  gave  a  more  detailed  account  of  it.  It  consists 
essentially  of  pain  in  or  about  some  parts  of  the  sole  of  the  feet.  The 
pain  is  apt  to  come  even  in  well-formed  feet,  and  to  persist  for  years.  It 
is  an  ache  or  burning  pain,  and  is  unaccompanied  by  marked  redness  or 
swelling,  nor  is  it  ever  complicated  with  other  sensory  or  motor  troubles. 

It  is  made  worse  by  heat  and  much  covering,  as  well  as  by  exercise, 
and  has  been  ascribed  by  Dr.  Gross  to  a  subacute  inflammation  of  the 
periosteum.  I  have,  however,  seen  at  least  two  cases  in  which,  after  some 
years  of  pain,  there  was  very  distinct  evidence  of  anchylosis,  and  joint- 
troubles  among  the  small  bones  of  the  foot,  so  that  I  am  disposed  to  regard 
it  as  due  originally  to  a  low  grade  of  inflammation  of  the  complicated 
joint  surfaces  of  this  member. 

I  give  five  cases  as  illustrations  of  this  annoying  malady. 

Case  XII. — The  patient,  a  man  of  20  years,  consulted  me  on  account  of 
a  pain  and  burning  in  the  feet.  He  was  tall,  in  fair  general  condition, 
but  subject  to  occasional  attacks  of  palpitation  of  the  heart,  which  were  at 
times  severe  and  prolonged,  and  for  which  neither  in  his  habits  nor  in  the 
heart  itself  could  I  find  a  competent  cause.  He  was,  however,  easily 
wearied  ;  and,  as  he  worked  in  an  iron-foundry,  was  apt  to  be  very  tired 
by  nightfall.  After  some  two  years  of  such  labour,  he  began  to  have 
every  evening  pain  and  ache,  with  burning.  By  and  by  it  came  earlier 
in  the  day,  and  at  last  attacked  him  whenever  he  was  an  hour  or  two  on 
his  feet.  Occasionally,  after  great  exertion,  the  feet  flushed  a  little,  but 
did  not  swell.  Summer  was  the  time  of  the  greatest  torment,  and  a  cool 
day  gave  more  or  less  relief.  After  a  time  the  pain  became  so  severe  that 
he  was  forced  to  seek  a  sedentary  occupation,  after  which  the  pain,  on  the 
whole,  became  less,  although  ready  to  appear  anew  whenever  he  took  too 
much  exercise  on  foot.  I  should  add  that,  although  some  years  have  now 
gone  by,  this  tendency  still  continues,  while  in  no  other  way  does  the 
patient  show  any  manner  of  disease. 

I  have  lately  asked  anew  concerning  this  case,  and  find  that  the  trouble 
still  persists,  some  fifteen  years  having  gone  by  since  it  began. 

The  feet  were  well  formed,  and  there  was  no  taint  in  the  ancestry,  and 
no  history  of  gout,  rheumatism,  or  syphilis.  It  was  a  mild  case  of  pedal 
pain. 

Case  XIII  In  June,  1871,  I  saw  the  next  instance  of  this  obstinate 

disorder.  Mr.  C,  a?t.  thirty-seven  ;  married.  A  healthy,  well-built  man, 
free  from  any  constitutional  taint,  and  never  having  had  gout  or  rheuma 
tism.  When  nineteen  years  of  age,  Mr.  C.  lived  on  a  farm  and  worked 
as  a  field-hand  to  learn  the  business.  After  a  few  months,  and  in  mid- 
summer, he  began  to  feel  in  the  feet  a  sense  of  weariness — a  fatigue  and  sore 
feeling,  as  if  he  had  walked  too  long.  As  this  grew  worse  it  came  to  last 
over  night,  and  was  then  eased  by  walking  in  the  morning.  At  last  the 
soles  became  so  sore  that  he  would  sometimes  crawl  down  stairs  in  the 
Xo.  CLI  July  1878.  3 


34        Mitchell,  Rare  Vaso-motor  Neurosis  of  Extremities.  [July 


morning  on  his  knees,  and  after  cooling  his  feet  with  pump-water  would 
pull  on  his  boots.  There  was  neither  redness  nor  swelling,  and  the  soles 
were  the  chief  seat  of  pain,  which  was  a  dull,  heavy  ache,  always  much 
under  the  control  of  temperature,  heat  increasing  and  cold  relieving  it. 
The  autumn  and  winter  brought  entire  ease. 

He  quitted  the  business  of  farming,  and  became  a  clerk.  During  nine 
years  he  walked  a  good  deal,  and  felt  each  summer  some  slight  return  of 
annoyance,  but  the  winter  brought  absolute  relief.  When  twenty-nine 
years  old,  a  change  of  business  brought  with  it  heavier  responsibilities  and 
a  great  increase  of  exercise  on  foot. 

The  first  warm  weather  in  May  caused  a  return  of  the  foot-trouble,  from 
which,  up  to  this  time,  nine  years,  he  has  not  been  altogether  without  dis- 
comfort at  any  time. 

The  pain  and  suffering  in  his  first  attack  were  unlike  those  of  the  other 
cases,  but  when  they  returned  they  differed  little  from  these.  The  heat 
of  summer  and  too  much  foot-covering  increased  the  pain  and  the  readi- 
ness with  which  exercise  caused  it,  while  cold  had  exactly  a  reverse  in- 
fluence. 

After  walking  for  a  time,  he  felt  as  if  there  was  a  cushion  under  the 
toes  and  the  ball  of  the  foot.  Then  the  foot  burned  and  pricked,  and  these 
latter  feelings,  which  were  so  sharp  at  times  as  to  amount  to  stinging,  be- 
came worse  for  a  little  while  when  resting  after  a  walk.  His  mode  of  re- 
lief was  to  bare  his  feet  and  place  them  on  a  higher  level  than  the  remainder 
of  his  body.  At  no  time  was  there  redness  or  swelling,  and  only  once  or 
twice  could  I  find  spots  of  tenderness  on  the  sides  of  the  feet,  which,  I 
should  add,  were  well  formed. 

This  case,  like  the  last  one,  persisted  under  every  mode  of  treatment  I 
could  devise,  and  is,  I  believe,  rather  worse  to-day  than  better. 

Case  XI V  My  next  case  came  to  me  from  Dr.  James  King,  of  Pitts- 
burg. The  patient,  aged  twenty-one,  managed,  at  the  time  I  saw  him, 
a  large  printing-office.  He  was  healthy  up  to  1864,  when,  after  an  ex- 
tended army  service,  he  had  ague,  which  clung  to  him  a  long  time.  Re- 
turning home,  much  weakened  in  health,  he  began  for  the  first  time  in  his 
life  to  have,  after  long  walks  or  after  standing  for  a  time,  vague  pains  in 
both  feet.  Disregarding  these,  he  continued  to  be  much  on  his  feet,  and 
engaged  in  a  business  which  taxed  severely  all  his  powers  ;  and  soon  his 
annoyance  increased  so  much  as  to  cause  him  to  seek  for  aid. 

When  I  saw  him  in  1868,  he  was  suffering  most  gravely.  Usually  he 
arose  in  the  morning  free  from  pain,  but  it  came  on  in  one  or  two  hours, 
and  increased  in  severity  as  long  as  he  remained  active  and  on  foot.  It 
thus  happened  that  by  nightfall  both  feet  were  aching,  and  so  painful  as  to 
make  further  exertion  impossible.  The  seat  of  pain  was  not  distinctly 
fixed,  being  rather,  as  he  said,  throughout  the  feet.  There  was  never  at 
any  time  swelling,  but  once  or  twice  a  month  some  great  excess  of  move- 
ment would  cause  the  feet  to  be  slightly  flushed.  At  times  also,  as  in  the 
evening  or  whenever  unusual  or  sudden  exercise  had  been  taken,  the  pain 
was  of  a  burning  character,  and  the  feet  throbbed.  At  such  times  they 
became  tender,  and  were  so  sore  that  pressure  or  the  effort  to  pull  on  a 
boot  caused  extreme  pain. 

The  patient  was  free  from  heart-disease  or  other  troubles,  functional  or 
organic,  and,  like  the  previous  case,  had  not  had  gout  or  rheumatism. 

As  in  the  other  cases,  the  summer  brought  more  intense  pain,  and  it 


1878.]    Mitchell,  Rare  Yaso-motor  Neurosis  of  Extremities.  35 


was  in  hot  weather  easily  induced  by  the  slightest  exertion  ;  while  winter 
brought  not  only  a  general  relief,  but  also  enabled  him  to  walk  much  longer 
without  producing  pain.  Having  learned  these  facts  very  early,  he  saved 
himself  suffering  as  much  as  possible  by  wearing  the  lightest  of  foot-cover- 
ings. Later  in  his  case  the  pain  was  chiefly  on  the  sides  of  the  feet,  and 
at  all  times  he  could  obtain  perfect  relief  or  insure  freedom  from  annoy- 
ance by  rest  in  the  recumbent  position.  In  October,  1868,  Dr.  C.  B. 
King,  of  Pittsburg,  writes  to  me  that  he  has  carefully  watched  the 
patient  while  applying  electricity,  and  that  he  has  never  seen  the  feet 
either  red  or  swollen.  He  adds  that  the  right  foot  is  the  worse  of  the 
two,  and  that  the  severest  pain  is  in  the  centre  of  the  sole.  He  could 
find  no  tender  points  when  the  patient  had  been  for  a  while  without  exer- 
cise, as  in  the  mornings ;  and  when  the  feet  were  worst  the  tenderness 
varied  in  position,  and  was  usually  general  and  not  acute  or  in  limited 
localities ;  neither  was  it  seated  in  the  muscular  tissues  of  the  feet,  an  ob- 
servation which  I  myself  confirmed  on  several  occasions. 

In  1875  I  saw  this  patient,  and  prescribed  various  treatments,  none  of 
which  helped  him  for  more  than  a  few  days.  At  one  time  iodides  seemed 
to  be  of  use,  at  another  blisters  and  cups,  hot  and  cold  douches.  Rest, 
galvanism,  all  manner  of  liniments,  and  a  variety  of  baths  were  tried  in 
vain.  During  his  disease  he  was  in  the  hands  of  the  ablest  and  most  in- 
genious of  our  profession  in  and  out  of  Philadelphia,  but  with  one  and  all 
the  result  was  the  same. 

Dr.  James  King  writes  me  recently,  Feb.  1878,  that  the  pain  still  con- 
tinues under  certain  circumstances.  In  spring  and  autumn  especially,  the 
approach  of  a  storm  always  causes  pain,  which  remains  until  the  weather 
becomes  clear.  In  summer  and  winter  storms  affect  him  less,  and  this 
form  of  evil  influence  is  intensified  by  any  depression  of  health.  Walking 
or  standing  increases  the  pain,  and  when  seated  he  turns  his  feet  inwards 
so  that  the  soles  face  one  another,  while  more  ease  is  obtained  by  elevat- 
ing the  feet.  He  has  tried,  since  I  saw  him,  various  changes  of  climate  and 
locality,  and  thinks  he  was  made  worse  by  the  use  of  electricity  and  acu- 
puncture. Attention  to  his  general  health,  free  use  of  quinia  and  of  cold 
water,  have  aided  him  most.  At  present  his  feet  are  habitually  cold.  I 
may  add  that  he  inherits  on  the  maternal  side  a  very  nervous  tempera- 
ment, and  that  his  father  suffers  from  hereditary  gout. 

Case  XV — In  November,  1874,  Dr.  Stone  brought  to  me  a  salesman, 
C.  H.  A.,  ret.  21,  in  a  state  of  great  suffering.  In  November,  1873,  with- 
out hurt  or  excessive  exertion,  this  young  man  began  to  have,  when  walk- 
ing or  standing,  pain-ache  and  burning  in  the  ball  of  the  left  foot.  It  cov- 
ered the  whole  ball,  and  thence  affected  the  heel,  but  never  the  intervening 
arch  of  the  foot.  The  right  foot  was  attacked  in  like  fashion  two  months 
later,  but  it  began  in  the  heel  and  passed  to  the  ball  of  the  foot.  The 
pain  was  intense,  was  made  worse  by  excessive  covering  of  the  feet,  was 
better  on  awakening  in  the  morning,  but  became  more  sore  during  the 
morning,  and,  as  he  rested  in  the  afternoons,  it  grew  then  less  annoying. 
There  has  been  all  along  a  literallv  drenching  sweat  of  the  feet.  When 
seen  by  me,  both  soles,  and  indeed  the  whole  of  the  feet,  were  a  little 
puffy  and  swollen.  The  calves  were  remarkably  flabby,  but  there  were  no 
spinal  symptoms.  So  great  was  the  pain,  that  the  patient  was  forced  to 
crawl  about.  No  constitutional  or  other  cause  could  be  assigned  for  this 
trouble.  The  feet  were  tender  at  times,  but  until  the  disease  had  lasted 
a  year,  mere  movement  of  the  toes,  without  pressure,,  caused,  no,  annoy- 


f 


36         Goo  dell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  [July 

ance.  I  exhausted  my  ingenuity  in  efforts  to  relieve  this  case,  which, 
however,  left  the  hospital  unaided.  To-day,  February  20th,  1878,  I  saw 
the  patient  again,  and  learned  that  very  slowly  he  has  become  better.  I 
observe,  however,  that  while  the  sweats  have  ceased,  and  the  pain  grown 
very  much  less,  three  of  the  smaller  toes  of  the  left  foot  seem  to  have  par- 
tially lost  power  to  extend  themselves,  and  that  the  metacarpo-phalangeal 
joint  of  the  third  toe  is  sore  on  motion,  and  that  there  is  considerable 
limitation  of  motion  in  the  metacarpo-phalangeal  articulations,  and  an  un- 
usual want  of  freedom  of  passive  motion  in  the  small  bones  of  the  carpus. 

Case  XVI  One  of  the  worst  cases  I  have  seen  came  to  me  from  Dr. 

Corson,  of  Norristown.  After  every  other  means  had  failed  in  my 
hands,  and  those  of  several  able  physicians,  Dr.  T.  G.  Morton  twice  ope- 
rated on  the  feet  in  the  manner  which  he  describes  in  the  following 
note  : — 

The  first  operation  :  a  narrow,  long,  straight  bistoury  was  carried  in  at 
the  most  prominent  part  of  the  heel  posteriorly,  and  all  the  tissues  were 
freely  divided  from  side  to  side ;  the  edge  of  the  knife  was  then  turned 
towards  the  os  calcis,  and  the  tissues  directly  on  the  bone  were  freely  in- 
cised, several  longitudinal  cuts  being  made. 

The  second  operation  was  similar  to  the  first,  save  that  the  division  of  the 
tissues  from  side  to  side  was  more  complete  ;  after  this,  a  portion  of  linen 
soaked  in  carbolized  oil  (1  pt.  to  15)  was  carried  through  the  puncture, 
and  the  wound  fully  stuffed  witli  it ;  at  the  end  of  three  days  this  was 
withdrawn,  and  the  part  poulticed. 

The  parts  healed  rapidly  in  each  instance. 

The  first  operation  gave  great  ease  for  three  months,  so  that  he  could 
walk  with  the  aid  of  a  cane.  Then  he  relapsed,  and  since  the  second 
operation  has  been  Avorse  than  before. 

Gout  and  rheumatism  at  times  afford  instances  of  painful  soles,  but  these 
get  well  readily,  and  the  still  rarer  form  of  tender  feet  which  follows 
typhoid  fever,  though  more  mysterious  in  origin,  also  ends  in  recovery 
after  one  or  two  months. 

Almost  as  rare  are  the  cases  of  tender  feet  from  syphilis.  I  have  seen 
but  two  cases — one  of  them  within  a  month.  In  both,  a  very  careful 
examination  after  prolonged  soaking  in  hot  water,  so  as  +o  soften  the  sole-, 
revealed  nodes  on  the  bones  of  the  feet.  In  both  instances  these  were  on 
the  heel,  and  caused  the  patient  to  walk  in  an  odd  fashion  on  the  ball  of 
the  feet,  so  as  to  save  the  diseased  parts  from  pressure. 


Article  II. 

A  Case  of  Spaying  for  Fibroid  Tumour  of  the  Womb.  By  William 
Goodell,  A.M.,  M.D.,  Professor  of  Clinical  Gynaecology  in  the  University 
of  Pennsylvania. 

Some  five  years  ago  Dr.  E.  Battey  startled  the  medical  profession  by  pro- 
posing the  removal  of  the  ovaries  for  those  mental  or  those  physical  disorders 


1878.]    Good  ell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  37 


in  women  upon  which  menstruation  exerts  a  pernicious  influence.  His 
theory  was.  and  a  plausible  one  it  is,  that,  since  many  of  these  disorders 
are  kept  up  by  the  monthly  afflux  of  blood,  and  are  therefore  incurable 
during  menstrual  life,  the  only  chance  for  their  immediate  relief  lies  in  the 
establishment  of  an  artificial  menopause.  To  effect  this  change  of  life  he 
advocated  the  extirpation  of  both  ovaries,  and  labelled  the  operation 
Normal  Ovariotomy.  TV~ith  this  name  fault  has  been  found,  because  it 
does  not  cover  the  whole  ground,  for  in  some  of  the  cases  operated  upon 
the  ovaries  were  themselves  diseased.  Now,  since  it  is  important  to  dis- 
tinguish this  operation  from  that  of  ovariotomy  proper,  and  since  it  is  not 
easy  to  define  it,  except  by  circumlocution.  I  shall  call  it  spaying — a  term 
which  as  technically  defines  the  character  of  the  operation,  as  that  of  cas- 
tration defines  the  analogous  operation  in  the  male. 

Amonsr  the  disorders  of  menstrual  life  which  are  made  worse  by  the 
monthly  determinations  of  blood  to  the  womb,  and  for  which  spaying  has 
been  successfully  tried  are  dysmenorrhcea,  convulsions,  pelvic  ha:ma- 
toceles,  and  pelvic  abscesses,  recurring  at  the  monthly  periods.  It  has 
also  been  resorted  to  for  supposed  ovarian  neuralgia,  for  hysteria  and 
insanity  with  menstrual  exacerbations,  and  for  epilepsy  with  an  ovarian 
aura.  The  success,  however,  in  these  latter  cases  has  been  qualified, 
because  the  origin  of  reflex  symptoms  is  not  always  discoverable ;  because 
pelvic  pains  need  not  have  an  ovarian  source  ;  because  hysteria,  epilepsy, 
and  insanity  may  be  imponderables,  or  sheer  brain  lesions,  and  wholly 
unconnected  with  the  sexual  apparatus. 

But  about  fibroid  tumours  of  the  womb  there  can  be  no  doubt.  The 
relation  here  between  cause  and  effect  is  unmistakable.  Their  growth 
and  their  morbid  effects  are  notably  increased  at  each  monthly  flux,  and 
notably  lessened  after  the  climacteric.  In  but  few  other  pelvic  disorders 
can  we  so  positively  single  out  the  ovaries  as  the  peccant  organs. 

Many  fibroid  tumours  of  the  womb  are  harmless,  giving  small  token  of 
their  presence.  But  when  once  they  begin  to  give  trouble  there  is  no 
limit  to  the  amount  of  suffering  they  may  cause,  while  the  means  of 
relief  at  our  disposal  are  limited.  Hypodermic  injections  of  ergotine 
often  fail ;  electrolysis  is  yet  in  its  infancy ;  avulsion  of  the  fibroid  or  its 
enucleation  can  rarely  be  performed  ;  whilst  the  removal  of  the  tumour  by 
abdominal  section,  or  the  extirpation  of  the  womb  itself,  are  among  the 
most  desperate  remedies  known  to  science. 

Now  if,  under  such  conditions,  we  could  by  any  means  so  lessen  the 
sexual  or  the  periodic  congestions  of  the  womb,  as  to  shorten  the  blood- 
rations  of  these  growths,  the  presumption  is  that  the  hemorrhages  would 
either  stop  or  abate,  that  the  pains  would  become  less  cruel,  and  that  the 
tumours  would  cease  to  grow.  "You  take  my  life,"  says  Shylock,  "when 
you  do  take  the  means  whereby  I  live."  The  ovaries  being  then  pre- 
eminently sexual  organs,  and,  therefore,  the  means  whereby  these  tumours 


38         Goodell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  [July 


live,  &  priori  reasoning  would  suggest  their  extirpation.  Let  us  see 
whether  such  logic  has  been  sustained  by  clinical  experience  : — 

Prof.  E.  H.  Trenholme,1  of  Montreal,  reports  a  case  of  interstitial  and 
subperitoneal  fibroids  of  the  womb,  in  which  the  health  began  to  fail  from 
intolerable  uterine  tormina  and  from  serious  metrorrhagia.  The  os  uteri 
was  on  five  occasions  slit  open  with  a  knife,  and  the  mucous  surface  of  the 
tumour  freely  cauterized  with  caustic  potash.  The  relief  following  these 
operations  being  only  temporary,  the  removal  of  the  ovaries  was  decided 
upon.  An  abdominal  incision,  five  inches  in  length,  being  accordingly 
made,  "  the  ovaries  were  found  low  down  in  their  normal  position,  and 
not  above  the  brim  of  the  pelvis,  as  the  position  of  the  uterus  and  fibroids 
would  lead  one  to  suspect."  Each  pedicle  was  ligated  with  carbolized 
white  dressmakers'  thread,  No.  20,  and  dropped  back.  The  patient 
recovered  without  a  bad  symptom,  and  on  the  twelfth  day  went  out  for  a 
sleigh -ride.  For  three  successive  months  after  the  operation  she  had  a 
uterine  hemorrhage.  It  then  ceased,  and  the  woman  "  gained  much  in  flesh 
and  strength."  Two  years  later,  under  the  date  of  January  28, 1878,  Prof. 
Trenholme  wrote  to  me  about  her  as  follows  :  "  There  have  been  occasional, 
but  not  regular  discharges,  to  the  extent  of  about  a  teaspoonful,  of  pure 
blood,  and  no  appearance  of  menses  otherwise.    Patient  is  well  enough  to 

be  at  a  medical  college  in   .    The  tumour  is  rather  smaller  than 

when  the  operation  M  as  made.    I  regard  the  operation  a  success." 

Two  other  cases  are  reported  by  Prof.  Hegar,2  of  Freiburg.  The 
women  were  perishing  from  hemorrhages  caused  by  irremediable  fibroid 
tumours  of  the  womb.  This  distinguished  gynaecologist  removed  both 
ovaries  from  each  woman  by  the  abdominal  incision.  In  each  case  con- 
valescence was  uninterrupted,  the  menopause  was  established,  and  the 
tumour  became  smaller.  A  fourth  case  is  an  unpublished  one  operated 
upon  by  Prof.  Nussbaum,  of  Munich,  and  evidently  with  success,  as  tin- 
following  extract  from  his  letter  to  me  would  imply:  "I  performed  the 
double  ovariotome  in  consequence  of  a  fibrous  state  o  the  womb.  In 
this  case,  the  period  appeared  twice  distinctly  after  the  operation,  and  then 
it  ceased  altogether." 

The  fifth  case  happened  in  my  own  practice,  and  is  as  follows : — 

A.  B.,  aged  33,  a  literary  maiden  lady,  began  to  menstruate  when  thirteen 
years  old,  but  always  with  pain.  Twelve  years  ago  sacral  pains  and  menor- 
rhagia  began  to  trouble  her,  and  her  dysmenorrhea  grew  worse.  Before 
long  a  constant  and  worrying  pain  developed  in  the  left  hypochondrium, 
which  was  unsuccessfully  treated  first  as  a  malarial  affection  of  the  spleen, 
and  afterwards  as  some  lesion  of  the  left  kidney.  Apart  from  this  pain, 
she,  in  the  autumn  of  1875,  began  to  suffer  at  her  monthlies  with  an  excru- 
ciating pain  in  the  left  ovarian  region.  It  was  a  "  twisting,"  a  "  rending," 
or  a  "  bursting"  pain,  as  she  described  it.  One  week  before  each  monthly 
period  this  pain  began,  and  steadily  grew  worse,  until  it  became  unbear- 
able. The  flow  then  appeared,  but  with  no  abatement  of  her  sufferings. 
It  lasted  not  less  than  a  week,  and  was  very  profuse.    Next  followed  a 

1  Obstetric  Journal  of  Great  Britain,  Oct.  1876,  p.  430. 

3  Medical  Times  and  Gazette,  October  27,  1877,  p.  466,  from  Centralblatt  fur  Gyne- 
kologie,  May  26,  1877,  No.  5. 


1878.]    Goo  dell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  39 


week  of  gradual  mitigation  of  all  these  distressing  symptoms.  Thus 
three  weeks  out  of  every  four  were  virtually  spent  by  her  in  bed.  Worn 
out  by  loss  of  blood  and  by  her  acute  pains,  which  were  finally  pronounced 
to  be  nervous  in  their  character,  she,  in  the  autumn  of  1876,  consulted 
my  friend.  Dr.  Weir  Mitchell.  He  at  once  suspected  a  uterine  origin, 
and,  in  October,  1876,  asked  me  to  see  her. 

The  lady  was  pale,  thin,  and  bloodless,  with  a  face  furrowed  by  acute 
suffering.  I  found  a  virginal  cervix  lodged  on  the  symphysis  pubis,  and 
a  sharply  ante-flexed  womb  imbedded  in  the  hilus  of  a  large  and  kidney- 
shaped  fibroid  tumour.  Although  the  sound  gave  a  measurement  of  but 
three  inches,  the  tumour  dipped  down  to  the  bottom  of  Douglas's  pouch, 
and  reached  up  to  a  point  two  fingers'  breadth  above  the  navel  and  to  its 
left.  The  unexpanded  cervix  pouted  out  from  one  side  of  the  tumour, 
bearing  to  it  the  same  relation  as  the  nose  bears  to  the  face.  The  fibroid 
was  plainly  subperitoneal,  and  not  amenable  to  treatment  per  vaginam. 

Thereafter,  Dr.  Mitchell  and  1  met  frequently.  We  first  tried  ergot, 
which,  although  evoking  very  severe  uterine  tormina,  increased  the  bleed- 
ing. Once,  indeed,  while  under  its  full  action,  she  flooded  so  profusely  as 
greatly  to  alarm  her  friends  and  her  attending  physician.  Gallic  acid  did 
better,  but  it  was  not  well  borne  by  the  stomach.  Various  other  remedies, 
both  local  and  constitutional,  were  resorted  to  without  any  benefit  what- 
ever. The  only  mixture  which  really  did  her  any  good  was  one  of  cinna- 
mon water,  containing  in  each  tablespoonful  ten  grains  of  ammonium 
chloride,  and  one-twelfth  of  a  grain  of  hydrargyrum  bichloride.  This 
was  given  thrice  daily,  and  on  it  she  at  one  time  seemed  to  thrive.  But 
the  improvement  was  transient,  and  she  soon  steadily  began  to  go  down 
hill.  Worn  out  by  her  sufferings,  she  became  a  monomaniac  on  the  sub- 
ject, and  gave  neither  Dr.  Mitchell  nor  myself  any  peace  until  she  had 
extorted  from  us  a  promise  to  extirpate  the  womb.  My  chief  objection 
to  the  operation  lay  in  the  encroachment  of  the  growth  upon  the  cervix, 
by  which  very  little  room  was  left  for  the  application  of  a  ligature. 

While  we  were  waiting  for  the  summer  to  pass  away,  I  happened  to 
recall  Trenholme's  case  (Hegar's  two  cases  had  not  yet  appeared  in  our 
medical  journals),  and  we  were  led  by  his  success  to  decide  upon  the 
removal  of  the  ovaries. 

Xo  sooner  was  this  decision  announced  to  our  patient  than  she  insisted 
upon  having  the  operation  performed  at  once.  She  indeed  grew  so  mor- 
bidly importunate  and  so  unreasonable  on  the  subject,  as  to  make  her 
friends  apprehensive  of  insanity,  but  we  firmly  waited  for  the  warm  season 
to  end.  On  October  4,  1877,  with  the  aid  of  Drs.  Weir  Mitchell,  John 
Ashhurst,  C.  T.  Hunter,  B.  F.  Baer,  and  W.  Heath,  I  proceeded  to 
operate.  After  placing  our  patient  on  her  side,  and  after  introducing  the 
duck-bill  speculum,  I  caught  up  by  a  uterine  tenaculum  a  fold  of  the  post- 
cervical  mucous  membrane,  and  with  a  pair  of  Kuchenmeister's  scissors 
incised  the  vagina  to  the  extent  of  about  an  inch  and  a  half.  The  perito- 
neum being  in  like  manner  snipped  open,  I  passed  in  my  left  index  finger. 
By  pressing  down  the  tumour  with  the  free  hand,  I  was  now  able  to  hook 
my  finger  into  the  sling  made  by  the  oviduct,  and  securely  hold  each 
ovary  alternately,  while  I  seized  it  with  a  fenestrated  forceps,  and  brought 
it  into  the  vagina.  The  stalk  of  each  one  was  next  transfixed  with  a 
double  fine  silk  thread  and  securely  tied.  The  ovaries  were  then  removed, 
the  ligatures  cut  off  at  the  knot,  and  the  stumps  returned  into  the  pelvic 
cavity.    The  right  ovary  looked  healthy,  but  the  left  contained  a  small 


40         Goo dell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  [July 


cyst.  Very  trifling  was  the  loss  of  blood  during  the  operation  ;  no  vessel 
needed  tying,  and  not  a  suture  was  put  into  the  vaginal  wound. 

Following  this  operation  there  was  an  immediate  eflacement  of  all  the 
facial  furrows  of  suffering.  From  that  day  she  lost  all  those  pains  and 
aches  which  had  embittered  her  menstrual  life.  No  special  surgical  symp- 
toms supervened,  and  her  convalescence  would  have  been  uninterrupted, 
but  for  the  reaction  from  the  previous  overstrain  of  her  nervous  system. 
An  hysterical  explosion  spent  itself  in  dyspnoea,  in  wandering  pains  and 
in  paroxysms  of  great  prostration  and  of  excessive  nausea.  By  firm  moral 
treatment  she  got  the  whip-handle  of  herself,  and  did  well.  For  two  weeks 
after  the  operation  her  linen  was  stained  by  a  slight  oozing  of  blood,  but 
whether  it  came  from  the  wound  or  the  womb  I  cannot  say. 

On  the  16th  she  went  home  with  hardly  a  pain  or  an  ache.  On  the 
20th  I  found  her  up  and  sewing.  November  19th  she  came  to  my  office 
in  the  highest  spirits,  overflowing  with  joy  and  gratitude.  She  had 
walked  at  one  stretch  last  week  ten  Philadelphia  blocks,  which  make  just 
one  mile.  She  sleeps  without  anodynes,  and  has  a  keen  appetite.  De- 
cember 7th  she  came  to  consult  me  about  the  merest  show  of  blood,  which 
began  five  days  ago  and  has  lasted  ever  since.  It  barely  stains  her  under- 
clothing, and  needs  no  guard  ;  but  she  feels  anxious  lest  it  should  turn 
out  to  be  an  effort  at  menstruation.  If  it  be  indeed  a  monthly  period, 
it  is  the  first  one  since  the  operation,  and  the  first  one  for  many  years 
which  she  has  not  spent  in  bed  and  in  great  agony;  The  Sunday  follow- 
ing she  walked  fully  one  mile  to  church,  joined  without  fatigue  in  its  rites, 
and  returned  home  on  foot.  So  impressed  was  she  by  this  proof  of  return- 
ing health,  that  she  at  once  wrote  me  a  grateful  letter  of  thanks. 

December  17th.  To-day  she  consulted  me  about  a  soreness  high  up  in 
the  vagina,  and  about  the  slight  weeping  of  blood,  which  had  not  yet 
stopped.  For  the  first  time  since  the  operation  I  examined  her,  and  found 
on  the  site  of  the  wound  a  small  caruncle  or  neuroma,  which  bled  at  the 
slightest  touch,  and  was  extremely  sensitive.  After  blunting  its  sensi- 
bility with  carbolic  acid  I  snipped  it  off.  I  took  this  opportunity  to  make 
a  careful  examination,  and,  to  my  surprise,  found  the  womb  astonishingly 
lessened  in  size,  fully  one-half.  Instead  of  reaching  to  two  fingers'  breadth 
above  the  navel,  the  top  of  the  tumour  now  lay  half-way  between  the  navel 
and  the  symphysis  pubis.  By  February  20,  1878,  she  had  gained  twelve 
and  a  half  pounds  in  weight,  and  was  looking  and  feeling  extremely  well. 
The  tumour  is  now  so  much  reduced  in  size  as  to  need  searching  after. 
That  portion  of  it  which  filled  up  Douglas's  pouch  has  disappeared.  The 
rest  lies  behind  and  below  the  pubic  arch. 

April  4th.  It  is  only  from  my  preArious  knowledge  of  her  case  that  I 
was  enabled  to-day  to  discover  a  slight  fibroid  enlargement  of  the  womb. 
This  information  was  gained  by  careful  double  palpation,  for  the  sound 
gives  a  natural  length  to  the  womb.  Since  this  date  I  have  repeatedly 
seen  her,  but  have  not  made  any  further  uterine  examination.  She  has 
not  passed  a  single  day  in  bed  since  her  convalescence  from  the  operation, 
and  practically  is  wholly  cured  of  her  disorder. 

Thus  we  see  that  clinical  experience  has,  to  a  remarkable  degree,  sus- 
tained the  logic  of  d  priori  reasoning,  and  that,  in  certain  conditions  of 
fibroid  tumour,  the  removal  of  the  ovaries  is  a  warrantable  operation. 
But  under  what  conditions  does  it  so  become  ?  And  does  it  offer  the  best 
chance  of  rescuing  a  woman  from  hopeless  suffering  or  from  an  early 


1878.]    Good  ell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  41 


death  ?  For,  of  course,  unless  there  be  danger  or  great  suffering,  no  such 
radical  operation  for  a  fibroid  tumour  of  the  womb  would  be  justifiable. 

Whenever  the  growth  projects  fairly  into  the  uterine  cavity,  there  can 
be  no  question  that  its  removal  by  avulsion  should  always  be  first  tried. 
Of  the  value  of  this  operation  I  can  speak  in  positive  terms,  having  per- 
formed it  six  times.  In  all,  the  operation  was  by  no  means  easy,  and  in  two 
very  tedious — the  tumour  being  removed  piece-meal — but  then  no  vestige 
of  the  parasite  was  left  behind,  and  the  women  were  restored  to  complete 
health,  save  in  one  instance,  in  which  death  from  heart-clot  took  place  on 
the  sixteenth  day  after  the  operation.  Unfortunately,  however,  the  fibroid 
does  not  often  lie  under  the  mucous  membrane.  Its  site  is  usually  under 
the  peritoneum  or  within  the  uterine  wall,  and  therefore  this  operation 
becomes  available  in  only  a  small  percentage  of  cases. 

In  instituting  a  comparison  between  spaying  and  the  enucleation  of  the 
fibroid  per  vaginam,  it  might,  at  first  blush,  seem  the  better  to  resort 
to  the  latter  means.  Firstly,  because  such  an  operation  would  bring 
about  an  absolute  cure.  Secondly,  because  the  tumour  is  a  foreign  body 
— an  excrescence — whose  removal  would  make  the  woman  a  more  per- 
fect creature.  Further,  the  ovaries  are  important  organs,  and  their 
extirpation  means  mutilation,  a  mutilation  causing  barrenness  and  possi- 
bly marked  psychological  changes.  Nor,  indeed,  can  we  positively  de- 
pend upon  such  a  mutilation  to  bring  about  the  menopause  or  any  reduction 
in  the  bulk  of  the  tumour.  But,  as  a  make-weight,  the  offending  growth 
is  generally  mural  or  subperitoneal,  and  therefore  inaccessible  ;  whilst  even 
in  that  rarer  form,  which  bulges  into  the  uterine  cavity,  the  operation  of 
enucleation  cannot  always  be  undertaken.  On  the  other  hand,  the  ovaries 
can  always  be  removed,  and  that  by  a  completed  operation  which  is  rela- 
tively less  serious  than  either  successful  or  unsuccessful  attempts  at  enucle- 
ation. Out  of  twenty-eight  cases  of  enucleation  collected  by  West,  four- 
teen proved  fatal.1  As  regards  three  of  my  own  cases,  in  which  the 
capsule  of  the  tumour  was  merely  cut  through  to  a  limited  extent,  and 
partly  peeled  off,  one  died  of  peritonitis  within  seventy-two  hours  ;  in  an- 
other the  tumour  subsequently  enucleated  itself ;  in  the  third  no  apprecia- 
ble change  took  place  in  the  tumour,  but  the  hemorrhages  ceased.  In 
view  of  these  facts,  I  am  by  no  means  sure  that  when  the  question  comes 
to  lie  between  the  removal  of  the  ovaries  and  the  gradual  enucleation  of  a 
fibroid  imprisoned  by  an  undilated  os  uteri,  the  former  will  not  be  the 
operation  of  the  future. 

When,  however,  vaginal  enucleation  is  impracticable,  and  the  question 
is  reduced  to  one  of  three,  viz.,  spaying,  or  enucleation  by  gastrotomy,  or 
the  extirpation  of  the  invaded  womb,  there  is  to  my  mind  but  one  answer, 
and  that  one  in  favour  of  spaying.  My  reasons  for  expressing  this  belief 
are,  the  greater  mortality  of  the  other  two  operations,  and  the  greater 


1  Diseases  of  Women,  p.  307. 


42         Goodell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  [July 

mutilation  made  by  the  last  one.  Thus  K>jeberle,  of  Strasbourg,  has  col- 
lected twenty  cases  of  gastrotomy,  with  extirpation  of  pedunculated  fibrous 
tumours  of  the  womb,  by  ligature  or  by  enucleation.  Yet,  although  these 
growths  had  stalks,  and  were,  therefore,  in  the  best  possible  condition  for 
being  removed,  twelve  women  out  of  the  twenty  perished.  Again,  Dr. 
Pozzi,  of  Paris,  has  published  an  elaborate  thesis  upon  The  Value  of 
Hysterotomy  in  the  Treatment  of  Fibrous  Tumours  of  the  Womb,  in  which 
he  furnishes  seventy-five  new  cases  of  this  operation  above  the  number 
previously  collected  by  Koeberle,  Caternault,  and  Pe*an.  His  statistical 
tables  thus  embody  one  hundred  and  nineteen  cases  in  which  gastrotomy 
was  performed  for  the  removal  of  fibroid  tumours  of  the  womb.  Of  these 
77  were  fatal  and  42  successful.  Arguing  from  18  other  cases,  10  of  them 
being  his  own,  Dr.  G.  Kimball,  from  whose  excellent  paper  on  Extirpa- 
tion of  the  Uterus1  I  glean  this  information,  makes  the  following  comment 
on  Pozzi's  statistics :  "  There  is  good  reason  to  believe  that,  upon  an 
honest  count  of  the  entire  number  of  such  operations,  it  would  be  seen 
that  but  a  small  proportion  of  them  have  ever  been  brought  before  the  pro- 
fession ;  and  as  for  results,  it  is  probably  not  unjust  to  suppose  that  at 
least  eight  out  of  every  ten  such  cases  have  proved  fatal."  <:  The  uterus," 
writes  Dr.  Thomas  Keith,  "  has  been  pretty  frequently  removed  in  Scot- 
land, but  all  the  cases  proved  fatal  with  the  exception  of  my  solitary  three. 
I  need  hardly  say  that  the  fatal  cases  are  never  published."2 

Thomas3  gives  two  tables.  In  one  there  are  recorded  18  deaths  to  6 
recoveries.  In  the  other,  which  he  deems  the  more  trustworthy,  there 
stand  11  deaths  to  one  recovery. 

In  view  of  such  a  frightful  mortality,  to  say  nothing  of  the  great  muti- 
lation of  the  survivors,  extirpation  of  the  womb  for  fibroid  tumour,  while 
not  absolutely  unjustifiable,  should  never  be  resorted  to  except  as  an  ex- 
treme measure  ;  and,  in  my  opinion,  not  until  every  other  known  means, 
including  spaying,  has  previously  been  tried.  I  am  not,  indeed,  sure  that 
in  cases  of  sessile,  fibro-cystic  tumours  existing  during  menstrual  life,  it 
would  not  be  well  first  to  try  to  arrest  their  growth  by  the  ablation  of  the 
ovaries,  before  resorting  to  the  major  operation. 

In  contrast  with  this  appalling  death-record,  every  published  case  of 
spaying  for  fibroid  has,  up  to  the  present  time,  proved  successful,  not  only 
in  so  far  as  life  is  concerned,  but  also  in  its  effect  upon  the  tumour.  But 
since  the  number  of  these  cases  is  too  small  to  establish  general  conclu- 
sions, it  would  here  be  a  pertinent  inquiry  to  analyze  all  the  known  cases 
of  spaying.  By  this  means  we  shall  discover,  firstly,  the  general  mortality 
of  the  operation  ;  and,  secondly,  the  relative  mortality  between  the  abdo- 
minal and  the  vaginal  incision. 

The  following  table  shows  the  number  of  times  the  operation  of  spaying 


1  Transactions  American  Medical  Association,  vol.  xxviii.  1877,  p.  322. 
3  Ibid.  3  Diseases  of  Women,  1874,  p.  520. 


1878.]    Good  ell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  43 


has  been  performed,  the  name  of  each  operator,  the  mode  of  operating,  and 
the  number  of  deaths  : — 


Onpra  tnr 

Number  of 
cases. 

Abdominal 
incision. 

Recovery. 

Death 

Vaginal 
incision. 

Recovery. 

Death. 

Dr.  K.  rJattey1  ..... 

12 

2 

2 

10 

8 

2 

Dr.  Marion  Sims2  .... 

7 

3 

2 

1 

4 

4 

Dr.  George  J.  Engelman3 

3 

3 

3 

Dr.  Hegar,  of  Freiburg4 

2 

2 

2 

Dr.  T.  G.  Thomas5  .... 

2 

2 

1 

1 

Dr.  E.  H.  Trenholme6 

2 

1 

1 

1 

1 

Dr.  Wm.  Goodell       ,  . 

2 

2 

2 

Dr.  E.  R.  Peaslee*  .... 

1 

1 

1 

Dr.  T.  T.  Sabine8       .        .     _  . 

1 

1 

1 

Dr.  J.  von  Nussbaum,9  of  Munich 

1 

1 

1 

33 

16 

10 

6 

17 

15 

2 

To  these  I  think  it  but  fair  to  add  the  seven  cases  of  vaginal  ovariotomy 
which  I  have  published  elsewhere.10  In  these  cases  the  cysts  ranged  in 
size  from  an  orange  to  the  womb  at  term,  yet  in  not  one  instance  was  the 
operation  followed  by  death. 

From  the  above  table,  then,  it  appears  that  out  of  a  total  of  thirty- 
three  cases  of  spaying  eight  have  died.  As  regards  the  relative  value  of 
the  two  modes  of  performing  the  operation,  it  will  be  seen  that  out  of 
sixteen  cases  in  which  the  abdominal  incision  was  employed  six  died  ; 
whilst,  out  of  the  seventeen  cases  in  which  the  ovaries  were  removed  by 
the  vaginal  incision,  only  two  died.  Now,  if  to  the  latter  be  added  the 
seven  cases  of  vaginal  ovariotomy,  we  shall  have  but  two  deaths  in  a  total 
of  twenty-four  cases  in  which  one  ovary  or  both  ovaries  have  been  removed 
per  vaginam. 

The  ancients  evidently  deemed  this  operation  a  comparatively  harmless 
one,  and  not  unfrequently  resorted  to  it.  Strabo  and  other  writers  aver 
that  "  certain  kings  of  Lydia  caused  the  ovaries  of  women  to  be  removed, 
using  them  sometimes  in  their  service  and  sometimes  for  their  pleasure."11 

1  Trans.  Am.  Gynaecological  Soc,  vol.  i.  p.  119. 

2  British  Med.  Journal,  Dec.  8, 1877. 

3  Personal  communication,  March  30,  1878. 

4  Centralblatt  f.  Gynakologie,  May  26, 1877,  No.  5. 
s  Trans.  Am.  Gynaecological  Soc,  vol.  i.  p.  352. 

6  Obstetrical  Journal  of  Great  Britain,  October,  1876,  p.  426. 

I  Trans'.  Am.  Gynaecological  Soc,  vol.  i. 

8  New  York  Med.  Journal,  January,  1875,  p.  41. 
3  Personal  communication,  February  12,  1878. 

10  A  Case  of  Vaginal  Ovariotomy.  By  Wm.  Goodell,  M.D.,  published  in  Transactions 
American  Gynaecological  Society,  vol.  ii.  1877. 

II  Ovarian  Tumours.    By  E.  R.  Peaslee,  M.D.,  ed.  1872,  p.  226. 


44         Goodell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  [July 


Then,  there  is  that  oft-told  story  of  the  Hungarian  sow-gelder,  who  is 
said  to  have  cured  the  lewdness  of  his  daughter  by  removing  her  ovaries. 
In  these  cases,  moreover,  the  incision  was  undoubtedly  abdominal.  Yet 
it  is  a  curious  fact,  established  by  Englisch,1  that  of  the  cases  in  which 
extirpation  of  a  healthy  irreducible  ovary  was  performed  for  hernia  of 
that  organ,  one-half  died  of  subperitoneal  inflammation  and  its  results. 

The  next  question  which  presses  for  an  answer  is  :  How  shall  the  ope- 
ration be  performed  ?  From  the  foregoing  table  it  appears  that  the  vaginal 
operation  is  the  safer  one.  This  is  undoubtedly  attributable  to  the  greatly 
lessened  exposure  of  the  peritoneum,  and  to  the  dependent  drainage  open- 
ing. Whether  it  is  as  easy  an  operation  as  the  other  remains  yet  to  be 
seen.  Whenever  the  ovaries  are  carried  up  by  a  large  tumour,  they  may 
lie  beyond  the  reach  of  the  finger  introduced  per  vaginam.  Yet  in  my 
case,  in  spite  of  a  tumour  of  great  size,  the  glands  were  caught  and 
extirpated  with  no  great  difficulty,  much  less,  in  fact,  than  in  my  second 
case  of  spaying,  one  for  pernicious  menstruation  threatening  insanity,  in 
which  there  was  no  tumour  to  dislocate  the  ovaries. 

In  an  analogous  case,  Trenholme  found  the  ovaries  "  low  down  in  their 
normal  position,  and  not  above  the  brim  of  the  pelvis,  as  the  position  of 
the  uterus  and  fibroids  would  lead  one  to  suppose."  Again,  strong  pelvic 
adhesions  may  interfere  with  such  a  mode  of  spaying.  Thomas  reports  a 
case  in  which  he  attempted  to  remove,  per  vaginam,  an  ovary  as  large  as 
an  egg,  but  failed  on  account  of  abundant  adhesions.2  The  gland  was 
finally  extirpated  by  the  abdominal  incision,  but  fatal  peritonitis  Bet  in. 
Sims  says  of  one  of  his  cases,3  "  The  ovaries  were  firmly  bound  down  by 
strong  bands  of  false  membrane,  and  it  was  impossible  for  me  to  dislodge 

them  I  was  forced  to  abandon  the  operation."  Battey 

writes  of  his  fourth  case  that,  owing  to  pelvic  adhesions,  "  it  was  found  to 
be  impracticable  to  isolate  the  gland  entire,  and  I  contented  myself  with 
such  disintegration  as  I  could  effect  with  my  finger-nail."  Cases  eight 
and  nine  of  his  series  4 'were  so  complicated  with  pelvic  deposits  of  lymph 
that  it  could  not  be  asserted  that  the  ovaries  were  cleanly  removed."  If, 
however,  the  operation  through  Douglas's  pouch  should  fail,  the  final 
resort  could  always  be  made  to  the  abdominal  incision,  and  the  abandoned 
vaginal  incision  be  utilized  as  a  drainage  opening. 

Candour  compels  me  to  note  one  very  serious  drawback  to  the  operation 
of  spaying.  For  some  inexplicable  reason,  the  removal  of  both  ovaries 
does  not  always  bring  about  the  desired  "Change  of  Life."  Ovulation, 
of  course,  ceases,  but  a  periodical  metrostaxis  may  go  on  as  before.  2s  ow, 
it  is  not  within  the  scope  of  this  paper  to  discuss  the  theory  of  this  non- 
ovular  menstruation  ;  whether  it  be  due  to  the  force  of  habit,  or  to  a  law 

1  Sydenham  Tear  Book,  1871-72,  p.  293. 

3  Transactions  American  Gynaecological  Society,  vol.  i.  p.  352. 
3  British  Medical  Journal,  December,  1877. 


1878.]    Goodell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  45 


of  periodicity,  or  to  some  fragment  of  ovarian  stroma  left  behind  by  the 
operator,  or  to  supplemental  ovarian  tissue  contained  between  the  perito- 
neal layers  of  the  Broad  Ligament.  What  we,  as  practieal  physicians, 
have  to  deal  with  is  the  important  and  unexpected  fact  that  uterine  dis- 
charges of  blood  sometimes  keep  on  long  after  the  ablation  of  both  ovaries. 
This  being  the  case,  it  will  be  pertinent  to  inquire  how  far  we  may  depend 
upon  such  an  operation  to  put  an  end  to  the  menstrual  flux.  In  other 
words,  what  proportion  of  women  who  have  lost  both  ovaries  menstruate? 

It  is  a  fact  worthy  of  note  that  during  the  week  following  the  ablation 
of  one  or  both  ovaries,  a  sanguineous  discharge  usually  takes  place  from 
the  womb.  This  happened  in  both  of  my  cases  of  spaying,  but  it  is  in  no 
wise  a  menstruation,  but  a  metrostaxis  set  up  by  the  irritation  of  the 
ovarian  nerves  caused  by  the  means  adopted  to  secure  the  pedicle.  It  is 
therefore  more  likely  to  happen  when  both  ovaries  are  removed,  for  then 
two  sets  of  ovarian  nerves  are  injured  by  the  clamp,  or  the  ligature,  or 
the  ecraseur.  Such  fluxes,  even  when  repeated  once  or  twice,  do  not  mean 
a  continuance  of  menstruation,  and  I  have  so  labelled  them  in  my  tables. 

To  obtain  the  data  for  the  following  tables  much  correspondence  was 
needed,  and  I  here  take  the  opportunity  of  recording  my  thanks  to  the 
distinguished  gentlemen,  at  home  and  abroad,  who  were  kind  enough  to 
answer  my  inquiries.  Among  the  last  letters  written  by  the  lamented 
Peaslee  was  one  giving  me  his  personal  experience  on  this  point. 

Table  of  Cases  in  ivhich  so-called  Menstruation  kept  on  after  the 
Removal  of  both  Ovaries. 


No. 

Operator. 

Age 

1 

Verneuil,  M. 

36 

2 

Storer,  H.  R. 

3 

Atlee,  W.  L. 

35 

4 

31 

5 
6 

40 

7 
8 

Meadows,  A. 

9 

Jackson,  R.  A. 

44 

10 

Le  Fort 

11 

Brown,  I.  Baker 

12 

Kceberle 

13 

Battey,  R. 

35 

14 

Thomas,  T.  G. 

15 

Kimball,  G. 

4S 

16 

Trenholme,  E.  H 

32 

17 

Burnham,  W. 

32 

18 

Thornton,  J.  K. 

24 

19 

Wells,  T.  S. 

29 

20 

Bird,  F. 

32 

Quoted  from 


Annales  de  Gynsecologie,  August, 
1877,  p.  143 

American  Journal  of  Med.  Sci., 

January,  1S68,  p.  81 
Atlee's  Ovarian  Tumours,  p.  35 

"         "  "        p.  38 

Personal   communication,  dated 

Dec.  17, 1877 
Lancet,  1S72,  p.  290 

Am.  Supplement  to  Obstet.  Journ. 

of  Great  Britain,  vol.  ii.  p.  5 
Chicago  Med.  Journ.,  Oct.  1S70, 

p.  5S5 


Peaslee,  Ovarian  Tumours,  p.  528 

Trans.  Am.  Gynsec.  Soc,  vol.  i.r 
1877,  p.  119 

Am.  Journ.  of  Obstetrics,  Oct. 
1877,  p.  665 

Personal  communication  of  Janu- 
ary 22,  1^78 

Obstetric  Journ.  of  Great  Britain, 
Oct.  1876,  p.  425,  and  per.  com. 

Personal  communication  of  Janu- 
ary 18,  1S78 

Obstetric  Journ.  of  Great  Britain 
Feb.  1878,  p.  723 

Diseases  of  Ovaries,  p.  431 

Lancet,  October  30.  1847,  p.  467 


Menstruation. 


None  for  6  months,  then  for  6 
months  every  alternate  mo. 
afterwards  regularly. 

Uninterrupted. 


For  5  months,  then  died. 

For  6  months,  was  then  lost 

sight  of. 
For  3  months  after  operation, 

and  then  was  lost  sight  of. 
Uninterrupted. 


Irregular. 

All  of  the  womb  excepting 

cervix  was  also  removed. 
At  intervals  of  from  3  to  7 

months. 
Irregular  for  6  months,  when 

last  heard  of. 
Irregular  for  5  months,  when 

she  died. 
Irregular  discharges  of  a 

drachm  of  blood. 
Regular,  but  less  in  quantity. 

Irregular,  but  with  relief  to 

flushes  and  headache. 
Uninterrupted. 


46         Goodell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  [July 


Another  very  curious  and  unexpected  fact  elicited  by  these  inquiries,  is 
the  recurrence  of  so-called  menstruation,  even  after  the  removal  of  the 
womb  itself  together  with  ovaries.  Koeberle1  notes  such  a  circumstance 
as  occurring  in  a  case  in  which  the  cervix  uteri  alone  was  left  behind. 
Storer2  completely  extirpated  the  womb  and  ovaries,  yet  on  the  nineteenth 
day  a  sanguineous  discharge,  lasting  thirty  hours,  took  place  from  the 
vagina.  Burnham  writes  to  me  that  after  such  an  operation,  44  several 
months  after  the  recovery,  seemingly  a  perfect  one,  there  occurred  from 
the  vagina  quite  a  copious  discharge,  tinged  with  blood,  which  continued 
for  one  day,  and  was  never  followed  by  any  recurrence." 

After  such  facts  as  these,  one  is  prepared  to  accept  the  further  state- 
ment that  menstruation  not  only  has  gone  on,  but  has  become  excessive, 
after  cystic  or  other  disease  has  invaded  both  ovaries  and  wholly  destroyed 
them — at  least,  apparently  so.  Examples  of  this  kind  are  furnished  by 
Buhring  and  Beigel,  and  by  Mayrhofer,3  who  quotes  them.  A  very  inte- 
resting case  is  told  by  M.  Terrier.4  He  removed  one  ovary  for  cystic  dis- 
ease. The  woman  died  two  years  after,  and,  although  the  remaining 
ovary  was  found  wholly  altered  and  cystic,  she  had  menstruated  up  to  the 
time  of  her  death.  Sinety  makes  an  analogous  observation,5  which,  how- 
ever, is  beyond  my  reach.  But  the  climax  is  reached  by  Atlee,6  who 
gives  two  cases  in  which,  one  ovary  having  been  removed,  the  other 
became  so  diseased  as  to  need  repeated  tappings,  and  yet  eacli  woman 
not  only  menstruated  but  gave  birth  to  a  child. 

From  these  tables  it  appears  that  out  of  ninety-eight  cases  of  extirpation 
of  both  ovaries  during  menstrual  life,  there  were  twelve  which  had,  so  far 
as  I  can  learn,  regular  monthly  fluxes,  and  eight  in  which  such  fluxes  were 
either  irregular  or  lessened  in  amount. 

This  is  a  large  average,  much  larger  than  one  would  suspect.  But, 
although  very  carefully  educed,  it  is,  I  am  sure,  untrustworthy,  and  for 
the  following  reason  :  Every  case  of  double  ovariotomy  has  not  been  pub- 
lished ;  but,  so  opposed  to  our  preconceived  ideas  is  the  recurrence  of  men- 
struation after  the  removal  of  both  ovaries,  that  every  such  case  has  been 
deemed  worthy  of  note.  Acting  on  this  presumption  I  have  included  in 
my  table  of  arrested  menstruation  some  cases  in  which  no  allusion  has 
been  made  by  the  operator  to  the  subsequent  menstrual  history ;  taking  it 
for  granted  that  had  a  monthly  flow  continued  the  fact  would  have  been 
deemed  of  sufficient  importance  to  be  noted. 

1  Peaslee  on  Ovarian  Tumours,  p.  528. 

3  Am.  Journal  of  Medical  Sciences,  January,  1865,  p.  119. 

3  Wiener  Medizimsclie  Wochenschrift,  Feb.  1875,  p.  130. 

4  Bulletin  et  Mem.  de  la  Societe  de  Chirurgie,  1876,  t.  ii.  p.  551. 
*  Bulletin  de  la  Societe  de  Biologie  ;  Seance  Decembre  2,  1872. 

6  Atlee,  Ovarian  Tumours,  pp.  38  and  39. 


1878.]    Goo  dell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  47 


Table  o  f  Cases  in  which  the  Removal  of  both  Ovaries  during  the  Men- 
strual period  of  life  was  followed  by  the  Cessation  of  the  Menses. 


Operator. 


Pott,  Percival 
Peaslee,  E.  R. 


Atlee,  J.  L. 
Atlee,  W.  L. 

llegar 

Storer,  H.  R. 
Kimball,  G. 

Thomas,  T.  G. 


Burnham,  "W. 

Dunlap,  A. 
Spiegelberg,  0. 


Age 


4S 


Quoted  from : — 


Peaslee  on  Ovarian  Tumours, 
p.  226 

Am.  Journ.  Med.  Sci.,  April, 

1851,  p  3S5 
Am.  Journ.  Med.  Sci.,  July, 

1664,  p.  47 
Am.  Journ.  Med.   Sci.,  July, 

1865,  p.  9S 
Personal  communication,  Jan. 

5,  1S78 

Personal  communication,  Jan. 
5,  1878 

Personal  communication,  Jan. 
5,  1878 

Personal  communication,  Jan. 
5,  1 87S 

Personal  communication,  Jan. 
5,  1878 

Personal  communication,  Jan. 
5,  1878 

Personal  communication,  Jan. 
5,  1878 

Personal  communication,  Jan. 
5,  1878 

Am.  Journ.  Med.  Sciences,  1S44, 
p.  44 

Ovarian  Tumours,  p.  36 

Personal  communication,  Dec. 
17, 1S77 

Ceutralblatt  f.  Gynek.,  May  26, 

1877,  No.  5 
Ceutralblatt  f.  Gynek  ,  May  26, 

1S77,  No.  5 
Chicago  Med.  Journ.,  Oct.  1870, 

p.  586 

Personal  communication  of  Jan. 
22,  1878 

Personal  communication  of  Jan. 
22,  1878 

Trans.  Am.  Gynsec.  Soc.  vol.  i. 

1S77, p.  352 
Am.  Journ.  of  Obstetrics,  Oct. 

1877,  p.  665 
Am.  Journ.  of  Obstetrics,  Oct. 

1S77,  p.  665 
Am.  Journ.  of  Obstetrics,  Oct. 

1877,  p.  665 
Am.  Journ.  of  Obstetrics,  Oct. 

1877,  p.  665 
Am.  Journ.  of  Obstetrics,  Oct. 

1877,  p.  665 
Am.  Journ.  of  Obstetrics,  Oct. 

1877,  p.  665 
Am.  Journ.  of  Obstetrics,  Oct. 

1S77,  p.  665 
Personal  communication  of  Jan. 

18,  1877 

Personal  communication  of  Jan. 
18, 1S77 

Personal  communication  of  Jan. 
18, 1877 

Personal  communication  of  Jan. 
18,  1S77 

Personal  communication  of  Jan. 
24,  1878 

Personal  communication  of  Jan. 
24,  1878 

Persona]  communication  of  Feb. 
11,  1878 

Personal  communication  of  Feb. 
11, 1878 


Remarks. 


No  menstruation. 


In  three  of  these  cases  there 
was  metrostaxis  occurring 
I  from  one  to  four  days  after 
the  operation,  and  con- 
tinuing from  two  to  four 
days." 


No  menstruation. 

No  red  menstruation,  but 

white  discharge. 
No  menstruation. 


One  sanguineous  discharge. 

"Menstruated  once,  but  only 
once." 

"  No  symptoms  of  menstruation 
of  any  kind  whatever." 

Metrostaxis  for  5  months,  then 
stopped. 

No  menstruation. 


One  profuse  discharge  ;  died  4 
months  later  from  cancer 

No  menstruation,  but  patient 
soon  lost  sight  of. 

Two  hemorrhages  at  3  months' 
interval. 

Menstruation  never  returned. 


1  "  Never  heard  that  these  wo- 
j   men  ever  since  menstruated. ': 


1  Although  this  w 
probiblyhave  cont 
operation. 


'man  wa 
Liued  se 


s  48  years  old  I  include  her  case,  because  her  menstruation  would 
veral  years  longer,  as  she  miscarried  of  twins  six  weeks  before 


48         Goodell,  Spaying  for  Fibroid  Tumour  of  the  Womb.  [July 


No. 


Operator. 


Quoted  from  :— 


Remarks. 


Nussbaum 


Baltey,  R. 


Clay,  C. 


Kceberle 
Brown,  I.  B. 
Byford,  W.  H. 


Sabine,  T.  T. 
Wells,  T.  S. 


Jackson 
Sims,  J.  M. 

Tait,  L. 

Emmet,  T.  A. 


Greene,  W.  W. 


Keith,  T. 


Goodell,  W. 


Personal  communication  of  Feb. 
12,  1878 

Personal  communication  of  Feb. 
12,  187S 

Personal  communication  of  Feb. 
12,  1*78 

Personal  communication  of  Feb. 
12,  lf>78 

Personal  communication  of  Feb. 
12, 1878 

Personal  communication  of  Feb. 
12, 187S 

British  Medical  Journal,  Dec. 
8,  1877 

Trans.  Am.  Gynaecological  Soc. 

vol.  i.  1877,  p.  110 
Trans.  Am.  Gynaecological  Soc. 

vol.  i.  1S77,  p.  119 

Chicago  Medical  Journal,  Oct. 

1S70,  p.  5S7 
Chicago  Medical  Journal,  Oct. 

1S70,  p.  587 
Chicago  Medical  Journal,  Oct. 

1870,  p.  o87 
Chicago  Medical  Journal,  Oct. 

WO,  p.  587 
Peasle<\  Am.  Journ.  Med.  Sci., 

Jan.  1S65,  p.  98 
Peaslce.  Am.  Journ.  Med.  Sci., 

Jan.  1865,  p.  98 
Personal  communication,  dated 

Dec.  28,  1S77 
Personal  communication,  dated 

Dec.  28,  1877 
Personal  communication,  dated 

Dec.  2S,  1877 
Personal  communication,  dated 

Feb.  11,  1S78 
Diseases  of  Ovaries,  1873,  p.  431 


One  metrostaxis. 

"  The  period  appeared  twice 
distinctly,  then  ceased  alto- 
gether." 

No  menstruation. 


Atresia  vaginae  ;  dreadful  men- 
strual molimina  cured. 
No  menstruation. 

For  several  months  menstrual 
molimina  came  back  without 

discharge. 


Throe  of  these  cases  had  one 

metrostaxis. 


No  menstruation. 


No  menstruation.    All  were 
underoiiservati>»n  from  two- 
aud  a  half  to  five  years  af- 
"le  operation. 


j     tor  th< 


"  Not  the  least  sign  of  menstru- 
ation." 
No  menstruation. 


"  p.  449 
"     p.  47.5 

Am.  Med.  Times.  Juno,  1862,  p. 
335 

Tait's  Diseases  of  Women,  Lond. 

1S77,  p.  2»5 
Personal  communication,  April 

2i,  1878 

Personal  communication.  April 
25,  1878 

Boston  Mod.  and  Surg.  Journ., 

March  2,  1&71,  p.  138 
Boston  Med.  and  Surg.  Journ., 

March  2,  1871,  p.  13t> 
Boston  Med.  and  Surg.  Journ., 

March  2,  1S71,  p.  138 
Boston  Med.  and  Surg.  Jouru., 

March  2.  1871,  p.  13S 
Edinburgh  Medical  Journal, 

Jan.  lSt56 
Ediuburirh  Medical  Journal. 

December,  1S66 
Edinburgh   Medical  Journal, 

November,  18o7 
Edinburgh   Medical  Journal, 

December,  1S67 


Second  ovary  forced  out  by 
vomiting,  and  shrunk  away. 
No  menstruation  whatever. 

One  metrostaxis. 

No  menstruation. 


|  Each  had  the  usual  sanguine- 
)-  ous  discharge  ouce,  and  one 
I  twice. 


|  Each  had  the  usual  sanguine- 
)-  ous  discharge  shortly  after 
I     the  operation. 


One  metrostaxis. 


1  In  the  British  Medical  Journal  (January  26,  1S7S,  p.  125)  eleven  additional  cases  of  double 
ovariotomy  are  reported,  but,  since  neither  the  age  nor  the  menstrual  history  of  the  patient 
is  given,  I  am  unable  to  utilize  them. 


1878.]    Goodell,  Spaying  for  Fibroid  Tumour  of  the  Womb. 


49 


The  actual  percentage,  then,  of  recurring  menstruation  is  not  large 
enough  to  deter  one  from  performing  this  operation  for  the  purpose  of 
establishing  the  menopause.  But,  granting  that  menstruation  keeps  on, 
will  its  continuance  impair  the  success  of  the  operation  ?  Now,  although 
menstruation,  in  the  sense  of  a  monthly  flow  of  blood,  may  not  cease,  yet 
ovulation  ends,  and  with  it  the  ovular  molimen.  Consequently  such  a 
metrostaxis  is  merely  a  blood-leakage,  and  therefore  unattended  by  that 
assemblage  of  nervous  and  congestive  determinations,  and  by  all  those 
reflex  symptoms  which  unite  to  make  up  the  molimen  of  pernicious  ovu- 
lar menstruation.  To  that  extent,  therefore,  may  we  hope  for  benefit. 
Thus,  in  Battey's  first  case,  although  an  irregular  uterine  hemorrhage  con- 
tinued, the  woman  was  cured  of  very  distressing  menstrual  symptoms,  for 
the  relief  of  which  the  operation  was  undertaken.  Trenholme's  case 
proved  a  success  in  spite  "  of  occasional  but  not  regular  discharges"  of 
blood. 

Does  spaying  after  puberty  unsex  a  woman  ?  So  far  as  can  be  ascer- 
tained it  does  not  ;  at  least  not  more  than  castration  after  puberty  unsexes 
a  man.  In  the  one  the  ability  to  inseminate  is  lost ;  in  the  other  the  capa- 
bility of  being  inseminated  ;  but  in  both  the  sexual  feelings  remain  pretty 
much  the  same.  Males  who  have  lost  their  testes  after  the  age  of  puberty 
retain  the  power  of  erection,  and  even  of  ejaculation;  but  the  fluid  is,  of 
course,  merely  a  lubricating  one.  The  amorous  proclivities  of  the  ox  or 
of  the  steer  are  the  scandal  of  our  streets.  Alive  to  these  facts,  oriental 
jealousy  demands  in  a  eunuch  the  complete  ablation  of  the  genital  organs.1 
Not  only  are  the  testes  therefore  removed,  but  also  the  scrotum  and  the 
penis.  Hence,  to  avoid  the  soiling  of  his  clothes,  every  eunuch  carries  a 
silver  catheter  in  his  pocket.  The  seat  of  sexuality  in  a  woman  has  long 
been  sought  for,  but  in  vain.  The  clitoris  has  been  amputated,  the  nymphae 
have  been  excised,  and  the  ovaries  removed,  yet  the  sexual  desire  has 
remained  unquenched.  Its  seat  has  not  been  found,  because  sexuality  is 
not  a  member  or  an  organ,  but  a  sense — a  sense  dependent  on  the  sexual 
apparatus,  not  for  its  being,  but  merely  for  its  fruition.  On  this  account 
I  have  quite  recently  refused  to  remove  the  ovaries  from  a  young  woman 
who  is  afflicted  with  uncontrollable  nymphomania,  although  both  she  and 
her  physician  urged  the  trial  of  the  operation. 

In  confirmation  of  these  views,  Battey  notes2  in  his  cases  of  spaying  the 
persistence  of  aphrodisiac  power — a  persistence  so  constant  as  to  forbid  any 
expectation  of  curing  nymphomania  by  the  operation.  Nor  in  any  of  them 
was  "  there  a  loss  of  the  womanly  graces,  but,  on  the  contrary,  the  patient 
gains  flesh,  and  becomes  even  more  attractive."    This  opinion  is  sustained 

1  North  American  Medico-Chirurgical  Review,  May,  1861,  p.  500  ;  New  York  Medical 
Record,  June,  1870,  p.  190 ;  Medical  and  Surgical  Reporter,  April  24, 1875,  p.  329. 

2  Transactions  American  Gynaecological  Society,  1876,  p.  119. 

No.  CLI  July  1878.  4 


50 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


[July 


by  Wells,  and  also  byPeaslee,  who  writes:1  u  Double  ovariotomy  as  a  rule 
is  not  followed  by  any  loss  of  the  special  characteristics  of  woman  ;  the 
only  decided  physiological  change  being  a  final  cessation  of  menstruation, 
as  well  as  of  ovulation.  Three  of  my  own  patients,  married  and  highly  edu- 
cated ladies,  after  recovery  again  became  splendid  examples  of  woman- 
hood, enjoying  the  most  perfect  health,  and  retaining  all  their  former 
attributes  of  mind,  as  well  as  of  body,  and  with  undiminished  sensory 
capacities  in  their  matrimonial  relations."  Atlee  reports  a  case  of  double 
ovariotomy,  in  which  marriage  took  place  after  the  operation,  as  "  the 
sexual  feelings  were  normal."  Six  months  after  the  operation  Verneuil 
found2  his  patient  with  well-developed  breasts,  and  decidedly  fatter.  "  She, 
in  fact,  seemed  far  more  of  a  woman  than  before  the  operation."  In  the 
one  of  my  two  cases  the  physical  condition  of  the  woman  was  in  every  way 
improved.  She  became  more  plump  and  better  looking.  All  traces  of  suf- 
fering were  effaced,  and  she  is  not  conscious  of  any  psychological  changes. 
In  the  other,  a  lady  under  the  professional  care  of  my  friend,  Dr.  Charles 
A.  McCall,  I  performed  the  operation  on  the  19th  of  last  March,  and  a 
sufficient  length  of  time  has  not  yet  elapsed  to  warrant  any  definite  con- 
clusions on  this  point.  I  may,  however,  say  that,  up  to  the  present  time, 
she  is  just  as  womanly,  and  as  much  of  a  woman  as  she  was  before  the 
operation. 


Article  III. 

On  the  Treatment  of  Uterine  Fibroids  with  Galvanism  by  Pro- 
found Puncture.  Illustrated  by  titty  cases  occurring  in  the  practice  of 
Gilman  Kimball,  M.I).,  of  Lowell,  and  Ephraim  Cotter,  M.D.,  of  Cam- 
bridge, Mass.    Reported  by  E.  Cutter,  M.D. 

The  fact  that  three-fourths  of  utero-abdominal  tumours  are  fibroids, 
and  that  they  have  hitherto  been  considered  practically  incurable,  justifies 
the  institution  of  new  methods  of  treatment.  With  this  view,  in  August, 
1871,  we  began  to  treat  uterine  fibroids  wTith  galvanism  by  profound 
puncture,  hoping  thereby  to  arrest  their  growth.  Up  to  the  present  time 
we  have  so  treated  fifty  cases,  with  the  following  results,  which  were  far 
beyond  our  most  sanguine  expectations.  In  seven  cases  the  growth  was 
not  arrested ;  four  died ;  in  thirty-two  the  growth  was  arrested ;  three 
cases  were  relieved,  and  four  cured. 

The  battery  and  electrodes  which  we  use  are  shown  in  Fig.  1,  and  were 
devised  specially  with  a  view  to  strength  and  portability.  The  battery 
consists  of  eight  plates,  each  of  carbon  and  zinc,  9  by  6  inches.  The 

1  Diseases  of  the  Ovary,  p.  530. 

3  Annates  de  Gynecologie,  August,  1877,  p.  146. 


1878.] 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


51 


first  four  pairs  are  arranged  Z.  C,  and  the  remaining  four  C.  Z.  They  are 
pierced  with  three  circular  holes,  arranged  triangularly  ;  two  at  the  top, 
and  one  in  the  centre,  below.  Cylinders  of  hard  rubber  run  through  and 
secure  the  plates  in  position  by  means  of  nuts.  The  conductors  are  made 
of  copper,  and  are  properly  insulated  ;  at  their  extremities  are  the  elec- 
trodes especially  devised  by  Dr.  Cutter  for  use  in  this  operation.  Fig.  2 
shows  the  rattan-lined  cells  and  the  tray,  and  Fig.  3  the  method  of  appli- 
cation of  the  electrodes.  The  solution  used  in  the  battery  is  made  by  the 
following  formula  :  Potassii  bichromate  (saturated  solution)  Oj  ;  sulphuric 
acid  3vij.  This  battery  recommended  itself,  as  we  were  impressed  with 
the  idea  that  quantity  of  current  was  what  was  required,  and  that  it 
must  lie  profoundly  applied,  and  the  galvanic  action  confined  to  the  tumour 
alone. 


Fig.  1. 


It  may  be  said  that  we  have  never  known  a  case  where  this  battery  was 
used  in  these  operations  in  which  the  zinc  electrodes  did  not  come  away 
readily  and  the  carbon  electrode  did  not  stick  in  the  tissues.  This  we 
cite  as  evidence  of  the  passage  of  a  galvanic  current  through  the  elec- 
trodes. 

The  duration  of  the  application  of  the  electrodes  has  varied  from  three 
to  fifteen  minutes.  In  each  individual  case  the  applications  have  varied 
in  number  from  one  to  nineteen,  at  intervals  of  from  seven  to  fourteen 
days.    The  patient  should  be  made  to  understand  that  the  operation  is  a 


52  Treatment  of  Uterine  Fibroids  by  Galvanism.  [July 

matter  involving  arrangements  whereby  she  may  lie  abed  and  be  cared  for, 
and  the  possible  severity  of  the  operation  and  the  risks  that  are  run  should 
be  impressed  upon  her.  The  operation  should  not  be  performed  hastily, 
or  without  the  most  careful  and  accurate  diagnosis  having  been  previously 
made. 

Fig.  2. 


CODMAN  &.  SHURTLEFF, 
BOSTON. 


Fur.  3. 


1.  Cases  in  which  the  progress  of  the  disease  was  not  arrested  by  the 
operation. 

Case  I — Mrs.  Robert  P.  (Reported  in  full  by  Dr.  W.  Symington 
Brown,  of  Stonebam,  Mass.,  in  Med.  and  Surg.  Rep.<  Feb.  8,  1^73.) 
Fibro-myoma.  Two  trials  of  galvanism.  Improved  feelings  after  second 
operation  ;  otherwise  no  favourable  result.  Patient  disgusted,  and  refused 
further  applications.  Death  from  exhaustion  and  hemorrhage,  Dec.  11, 
1872.  Date  o  f  operations :  Aug.  21,  1871,  two  needles  applied  through 
the  vagina.    Current  passed  fifteen  minutes. 

Eight  days  later,  Aug.  29,  Dr.  Kimball  was  present,  and  passed  the 
needles.    Current  continued  ten  minutes. 

Autopsy  made  by  Dr.  Brown.  Weight  of  tumour,  uterus  and  append- 
ages, four  pounds. 


1878.]  Treatment  of  Uterine  Fibroids  by  Galvanism. 


53 


This  case  is  of  interest  because  it  was  the  Jirst  of  and  the  occasion  of 
the  present  series  of  cases.  Its  full  history  shows  how  these  operations 
came  about.  It  shows  also  the  natural  history  of  a  fatal  termination  of 
the  case  itself  in  death.  It  was  the  first  case  where  a  regular  and  deter- 
mined effort  was  made  to  try  the  effect  of  electricity  upon  a  regularly 
diagnosticated  case  of  uterine  fibroid,  proved  to  be  so  after  death. 

If  there  had  not  been  a  fixed  determination  to  settle  the  question,  the 
result  of  this  case  would  have  deterred  us  from  any  further  procedures. 
We  were  disappointed,  but  not  discouraged.  The  encouraging  systemic 
improvement  was  overlooked  in  the  general  cloud  of  dissatisfaction  that 
settled  down  over  this  case. 

Case  II. — Mrs.  Morse,  Waltham,  Mass.,  40  years  of  age,  dressmaker. 
Size  suggests  a  six  months1  pregnancy.  Fibroid  involves  the  body,  but 
not  the  cervix  uteri.  Frequent  micturition.  Obliged  to  abandon  her 
occupation  on  account  of  this  disease. 

April  21,  1874.  First  application.  Ether.  Electrodes  penetrated 
through  the  abdominal  walls  3^  inches.    Current  ten  minutes. 

24th.  Second  application. 

May  24.  Third  application.  The  tumour  had  increased  in  size.  Free 
oozing  of  serum  through  punctures.  Other  operations  proved  it  to  be 
obstinate.  The  tumour  was  removed  by  Dr.  Kimball  by  the  abdominal 
section.  It  was  attached  by  a  broad  band  to  the  uterus.  The  interstitial 
uterine  portion  gave  no  evidence  of  its  existence.  It  had  disappeared. 
The  patient  recovered  perfectly,  and  was  alive  at  last  accounts.  Because 
Cesarean  section  was  resorted  to  before  relief,  this  case  was  ruled  to  be  a 
failure  for  galvanism.  Still  it  should  have  the  credit  of  the  dissidence  of 
the  uterine  portion. 

Case  III  Mrs.  M.,  Waltham,  44  years  old,  May  13,  1875  ;  married 

nineteen  years.  Menorrhagia  ever  since.  Childless.  Dressmaker.  Fi- 
broid perceptible  for  eight  years.  Size  indicates  a  weight  of  twelve  or 
fifteen  pounds.  Suffers  from  pressure  and  distension.  Lost  flesh  of  late, 
and  finds  the  duties  of  her  trade  fatiguing  and  irksome. 

This  day  galvanism  applied.  One  electrode  through  abdomen,  and  the 
other  per  vaginam.    Sense  of  nervous  prostration. 

June  11.  Both  electrodes  through  the  abdominal  wall.    No  trouble. 

15^/?.  Last  operation  repeated. 

17 fh.  One  electrode  through  abdomen,  and  the  other  through  vagina. 
No  relief  or  arrest.    Patient  alive.    Condition  as  before  operating. 

Case  IV. — Miss  Doudiet,  school-teacher,  New  Haven,  Ct.,  35  years 
old.  She  has  submitted  to  a  few  operations  with,  as  yet,  no  relief  nor 
arrest.    In  progress. 

Case  V  1877,  Feb.  1.   A  married  Irish  woman,  multipara,  was 

operated  on  for  a  fibroid.  No  injury  or  other  effect  was  produced  except 
to  frighten  her  husband,  who,  when  Dr.  Kimball  proceeded  to  his  house  to 
apply  the  battery  for  the  second  time,  strongly  and  bulldoggishly  objected 
on  monetary  grounds,  and  further  treatment  was  suspended.  Not  heard 
from  since. 

Case  VI  Mrs.  H.,  married,  40  years  of  age.    Chicago.    Seen  by 

Prof.  Byford,  Drs.  Fisher,  Hyde,  Clark,  Fitch,  W.  C.  Smith,  and  Dr. 
Jones,  family  physician.    All  coincided  in  the  diagnosis  of  growth  in 


54 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


[July 


pelvis,  attached  to  and  incorporated  with  the  uterus.  Multilobar  tumour 
in  abdomen.  Fibre  ovarian.  One  puncture.  Operation  not  completed. 
It  was  recommended  to  use  a  small  battery  per  cutan  method. 

Case  VII — Mrs.  S.,  Boston.  Large  tumour.  Passed  over  as  hope- 
less and  incurable,  as  several  applications  were  made,  all  without  good  or 
bad  result.  Life  became  such  a  burden  that  gastrotomy  was  resorted  to, 
and  the  tumour  removed.  Death  from  peritonitis,  fourteen  days  after- 
wards. Present  Drs.  F.  Semeleder,  of  Mexico,  Bixby,  of  Boston,  Conn, 
of  Concord,  N.  H.,  and  Cutter. 

II.  Fatal  cases. 

Case  VIII — In  1804  Miss  H.,  Portsmouth,  N.  II.,  consulted  Dr.  Kim- 
ball for  a  fibroid  tumour.  Told  that  nothing  could  be  done.  Ten  years  after, 
June,  1 874,  she  was  28  years  of  age,  unmarried.  Tumour  very  much  larger. 
Although  not  in  a  very  promising  condition,  her  importunity  was  yielded 
to,  and  galvanism  applied  the  day  after  her  arrival.  Aspiration  punctured 
a  cyst  apparently,  but  only  bloody  serum  was  procured.  Copious  flow  of 
serum  followed  the  introduction  of  the  electrodes,  running  through  the 
grooves  ;  continued  twenty-four  hours.  There  was  a  decided  diminution, 
probably  owing  to  the  evacuation. 

A  second  operation  was  performed  later  in  June.  There  was  pain 
in  the  abdomen,  vomiting,  headache,  prostration,  etc.  All  disappeared 
in  twenty -four  hours.  Later  in  the  same  month  a  third  operation  was 
performed.  Greater  pain,  more  prostration,  and  severe  vomiting  followed, 
but  disappeared  on  the  following  day.  The  patient  was  confident  that 
the  tumour  was  lessened.  The  bad  symptoms  recurred,  combined  with 
those  of  typhoid  tever  of  an  asthenic  type,  of  which  she  died  in  about 
four  weeks  after  the  last  operation. 

This  was  the  first  fatal  case  that  occurred.  It  is  possible  that  it  was  a 
malignant  form ;  no  autopsy.  The  patient  had  made  up  her  mind  for  the 
operation  from  hearing  of  other  cases.  In  this  curious  psychological  con- 
dition nothing  is  satisfactory  but  trying  the  ordeal.  When  held  back  one 
said,  ktI  don't  care  if  I  do  die."  This  result  teaches  that  the  surgeon 
should  not  allow  his  acting  against  the  dictates  of  his  judgment. 

Case  IX. — A  childless  Avife.  aged  50  years,  consulted  Dr.  Kimball. 
Noticed  her  fibroid  in  February,  1*74.  Pelvic  and  abdominal.  Hardish 
feel  and  equivocal  touch.  Thought  it  might  be  ovarian,  but  decided  it 
was  as  stated. 

Feb.  '75  Galvanism  was  applied  once;  through  the  abdominal  walls 

for  ten  minutes.  Next  day,  feeling  nicely,  she,  contrary  to  orders,  got 
up,  put  on  her  clothes,  and  went  about  the  house  as  if  nothing  had  hap- 
pened. The  house  was  not  warmed  by  furnace  or  steam  heat,  and  as  some 
rooms  were  cold  naturally  she  was  exposed,  took  cold,  and  went  back  to 
bed  sick.  Abdomen  swelled  and  bloated;  temperature  100°;  pulse  slow. 
Death  occurred  six  weeks  after  the  operation. 

The  autopsy  showed  no  morbid  changes  about  the  site  of  punctures, 
but  a  rent  one  inch  in  length  was  discovered  on  the  deep  part  of  the 
cyst,  opposite  the  punctures. 

The  history  up  to  the  time  of  her  getting  up  against  advice  and  exposing 
herself  is  that  of  many  other  cases.    For  this  reason  it  is  felt  hardly  just 


1878.] 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


55 


to  charge  her  death  to  the  interference.  We  have  no  desire  to  shirk  respon- 
sibility and  insert  it  in  its  place  with  a  recommendation  to  a  favourable 
consideration.  The  sad  result  brought  some  bad  reputation  on  the  opera- 
tion with  those  who  did  not  know  all  the  facts. 

Case  X  Mrs.  Underwood,  Rockland.  Mass..  widow,  50  years  old  in 

1874.  One  child.  Abdominal  tumour,  at  first  very  hard;  after  two 
applications,  assumes  a  cystic  form  ;  diminution  ;  returned  home  and  re- 
mained two  months. 

When  she  came  back  to  the  hospital  for  the  third  operation,  the 
tumour  was  found  to  have  changed;  became  soft,  and  felt  like  a  mono- 
cyst  :  no  pain,  but  mental  trouble  from  her  bulk;  at  the  application,  fluid 
of  a  sanguinolent  character  copiously  exuded  through  the  punctures. 
This  was  not  followed  by  chill  or  fever,  but  her  case  assumed  a  typhoid 
aspect;  si  ill  she  was  able  to  return  home  shortly  after.  She  foolishly 
refused  to  have  a  physician  until  moribund.  Her  symptoms  were  of 
septicaemia.  She  died  in  fourteen  weeks  after  the  third  operation.  No 
one  knows  but  that  she  might  have  recovered  had  she  received  even 
ordinary  attention.     She  had  better  have  remained  in  the  hospital. 

Case  XI. — 1876,  Aug.  4,  Miss  F.  C.  C,  Stoneham.  Mass.,  spinster, 
age  44.  presented  herself  to  Dr.  Cutter  to  have  galvanism  applied  to  a 
large  fibroid  of  ten  years'  standing,  that  blocked  the  pelvis,  packed  the 
vagina,  and  crowded  the  rectum.  The  .  uterus  could  not  be  detected. 
Eight  to  ten  small,  freely  moving  lobes  could  be  readily  felt  in  the  abdo- 
men, which  was  tender.  She  stated  that  her  sufferings  had  been  so  acute 
that  she  used  5j.  sulphate  of  morphia  weekly,  and  that  her  hope  was  to 
be  able  to  dispense  with  her  drug  if  the  operation  relieved  her  pain,  as  it 
had  remarkably  done  in  a  case  she  knew  of.  She  understood  and  took  all 
the  risks. 

Aug.  12.  Present,  Drs.  F.  A.  Sawyer,  of  Wareham,  and  F.  H. 
Luce,  of  Falmouth.  Mass.  One  electrode  was  passed  through  the  rectum 
and  one  through  the  abdomen,  right  of  navel.  Ten  minutes.  Pulse 
did  not  vary  from  86°  throughout.  Subsequently  there  was  vomiting 
and  pain,  but  her  great  pain  was  gone,  and  she  importuned  for  another 
application.  She  was  put  off  till  August  24th,  when  the  operation  was 
repeated.  Ten  minutes.  The  systemic  symptoms  owing  to  the  morphia 
habit  showed  no  sign  of  too  great  a  dose. 

29th.  Pale  and  prostrated ;  pain  over  puncture;  pulse  a  little  quick- 
ened. 30th.  Worse ;  severe  colic ;  right  hypogastric  region  swelled. 
Sept.  4th.  Pulse  96°  ;  resp.  24;  comparatively  comfortable;  coarse  rales 
scattered  here  and  there  through  the  chest;  belly  swelled  and  tender; 
conscious  and  rational.  8th.  Death  from  peritonitis  occurred.  Dr. 
Luce,  of  Falmouth,  her  physician,  writes :  pulse  120  to  130,  small;  temp. 
103°  to  104°;  nausea,  and  finally  delirium  before  demise;  no  autopsy. 

When  the  deep  penetration  of  the  abdominal  cavity  in  these  proced- 
ures is  considered,  it  appears  remarkable  that  more  deaths  have  not 
occurred.  It  seems  as  if  the  galvanic  current  confers  immunity.  Xo 
inflammatory  results  were  reported  in  Gen.  Kilpatrick's  angiomatous 
cervical  tumour,  which  was  cured  by  a  constant  current  in  one  application 
of  half  an  hour.  Four  deaths  out  of  fifty  cases  does  not  give  a  large  per- 
centage for  so  grave  an  operation  as  this.    It  hardly  seems  right  to  deny 


56 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


[July 


to  a  victim  of  morphia  the  chances  of  the  benefits  of  the  operation,  but 
this  instance  teaches  extra  caution  and  moderation. 

III.  Cases  in  which  the  progress  of  the  disease  was  arrested  by  the  op- 
eration. 

Case  XII. — Mrs.  F.,  of  Springfield,  Mass.  This  was  the  .second  case 
in  point  of  time.  Dr.  D.  F.  Lincoln,  of  New  York  City,  furnished  two 
electrolysis  needles  six  inches  long,  one  and  one-sixteenth  of  an  inch  in 
diameter,  cylindrical  platinum  tips,  body  insulated.  Patient  aged  LO, 
married.  The  tumour  was  a  large  pelvic  fibro-myoma  of  several  years 
growth,  very  hard  and  irregular;  filled  the  pelvis,  and  rose  up  in  the  ab- 
domen to  an  extent  indicating  a  seven  months'  pregnancy.  The  frequent 
metrorrhagia,  marked  anemia,  prostration,  rapid  increase  of  tumour,  and 
the  almost  unbearable  distension  bespoke  its  true  character.  Operated 
upon  at  Lowell  Dec.  2Gth,  1871.  Present,  Drs.  Kimball  and  Cutter. 
No  ancesthetic  was  used.  Two  electrodes  were  introduced  through  the 
abdominal  walls  about  six  inches  apart  on  either  side  of  the  median  line. 
They  extend  with  great  difficulty;  became  twisted  and  bent.  The  pene- 
tration was  only  three-quarters  of  an  inch.  A  penetration  of  three  or 
four  inches  at  least  was  intended.  Current  passed  seven  minutes.  The 
pulse  rose  from  70°  to  120°.  Lost  its  fulness;  the  face  became  pale  and 
pinched;  cold  sweat  covered  the  forehead  ;  hands,  feet,  legs,  and  forearms 
were  pale  and  cold.  The  patient  uttered  half-suppressed  expressions  of 
intense  agony.  Death  seemed  imminent.  The  operation  was  followed 
by  considerable  prostration  and  sharp  abdominal  pain  lasting  several  days. 
1872,  Jan.  1.  The  operation  was  repeated  in  the  same  manner  exactly, 
and  with  very  similar  systemic  results. 

For  six  weeks  after,  Dr.  Kimball  daily  observed  the  patient.  No  spe- 
cial change  was  noticed  as  regards  the  tumour;  certainly  no  increase  in 
size  appeared — a  fact  of  great  significance,  considering  that  for  weeks  pre- 
vious to  the  first  application  the  growth  ivas  rapidly  advancing,  and 
causing  great  suffering  from  distension.  Defective  and  unsatisfactory  as 
were  the  experiments  in  this  case,  owing  to  the  imperfect  construction  of 
the  electrodes,  the  effect  upon  the  general  condition  of  the  patient  proved 
on  the  whole  very  gratifying.  Within  three  weeks  from  the  first  trial, 
her  general  health  began  to  improve,  appetite  and  strength  returned;  the 
tumour  was  arrested;  at  last  accounts  patient  was  living  at  Newton,  Mass., 
much  benefited. 

This  case  was  reported  in  the  Boston  Med.  and  Surg.  Journ.,  Jan.  29th, 
1874,  p.  108.  It  showTs  the  natural  history,  so  to  speak,  of  the  operation 
without  ancesthesia.  The  Hippocratic  countenance  and  the  systemic  signs 
of  collapse  all  point  to  an  exhibition  of  a  very  profound  influence.  It 
shows  that  it  is  cruel  and  dangerous  not  to  use  anaesthesia. 

This  case  was  also  the  first  one  in  which  the  electrodes  were  plunged 
directly  through  the  abdominal  peritoneum.  The  credit  of  this  belongs  to 
Dr.  Kimball. 

After  the  operations  on  Case  XII.  it  was  decided  that  the  essays  must 
be  abandoned  unless  some  better  needles  could  be  devised  that  would,  for 
example,  penetrate  a  bullock's  testicle.  Such  an  instrument  would,  it  was 
thought,  meet  the  requirements.    It  was  the  lot  of  the  writer  to  undertake 


1878.] 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


57 


to  supply  this  want ;  noticing  the  twisting,  it  was  thought  best  to  have  it 
done  before  introduction.  So  an  electrode  was  produced  fashioned  like  a 
cork-screw.  This  showed  that  the  difficulty  lay  in  the  cylindrical  form. 
The  tissues  bind  on  the  whole  periphery  of  the  needle  because  they  gripe 
all  round.  If  this  gripe  could  be  relieved  the  needle  would  penetrate  more 
readily. 

Casting  about  for  expedients,  a  surgeon's  director  was  selected ;  this 
gave  much  promise,  and  time  has  perfectly  realized  it.  Without  disparaging 
other  needles,  it  can  be  truly  said  that  this  one  has  never  disappointed  ex- 
pectations, and  no  better  needle  has  been  desired. 

Case  XIII  Mrs.  T.,  widow,  Hubbardston,  Mass.,  40  years  old,  child- 
less. Large  pelvic  and  abdominal  fibro-myoma.  Anasarca,  ascites,  or- 
thopnea. 

"  The  first  experiment  with  the  battery  was  made  Nov.  26,  1873,  under 
the  direction  of  Dr.  Cutter.  His  newly  constructed  electrodes  were  used 
for  the  first  time."  No  anaesthesia.  One  needle  penetrated  through  the 
abdominal  walls  four  inches  instead  of  three-quarters  of  an  inch  in  Case 
XII.  Current  five  minutes ;  local  suffering  severe  for  the  first  twelve 
hours.  The  urinary  secretion  was  quadrupled  in  quantity.  In  less  than 
one  week  the  dropsy  disappeared  altogether.  But  the  most  striking  effect 
was  the  almost  instantaneous  and  perfect  relief  from  the  dyspnoea.  For 
the  first  time  in  many  months  she  was  permitted  to  lie  down  in  bed  and 
enjoy  rest  and  sleep  equal  to  that  of  the  healthiest  period  of  her  life. 
After  a  short  period  a  second  application  was  made.  One  electrode  through 
the  abdominal  wall  and  the  other  through  the  vagina  ;  three  inches.  Four- 
minute  current. 

"  The  third  and  last  operation  two  weeks  later.  The  tumour  became 
sensibly  diminished  in  size.  May  1  Dr.  Kimball  departed  for  Europe, 
and  no  further  applications  were  made.  The  condition  of  the  patient,  so 
recently  giving  promise  of  a  permanent  relief,  gradually  gave  way  to  a 
return  of  her  previous  bad  symptoms.  Death  occurred  about  the  middle 
of  July,  ten  weeks  after  she  was  last  seen  by  Dr.  Kimball. 

"  As  regards  what  might  have  been  the  result  of  a  longer  continued  ap- 
plication, it  is  of  course  a  matter  of  mere  conjecture ;  but  allowing  the 
case  to  have  been  absolutely  beyond  the  reach  of  cure  by  any  known 
remedy,  the  power  of  galvanism  in  affording  such  relief  from  suffering,  as 
shown  in  this  particular  instance,  furnishes  sufficient  reason  for  regarding 
it  as  something  better  than  a  therapeutic  agent  of  a  merely  fancied  value." 
(Reported  in  full  in  Boston  Med.  and  Surg.  Joarn.,  Jan.  29,  1874, 
p.  110.) 

Case  XIV  Mrs.    Peters,    coloured,  a  patient  of  Dr.    W.  G. 

Wheeler,  of  Chelsea,  Massachusetts  (to  whom  acknowledgment  is  here 
given  for  assistance,  encouragement,  and  share  of  responsibility),  age 
41  years,  childless.  Tumour  an  enormous  multilobar,  very  dense  fibro- 
myoid  of  ten  years'  standing.  March  2,  1875.  Great  distension  from 
ascites.  Largest  abdominal  circumference  forty-four  inches.  Several  times 
she  had  suffered  from  severe  peritonitis.  These  attacks  were  quite  serious, 
confining  her  to  bed  about  three  days  at  a  time  ;  at  other  times  the  weight 
and  tenderness  were  productive  of  much  suffering,  and  she  was  almost 
disabled.  This  day,  in  the  presence  of  Drs.  Wheeler,  Shackford,  and 
Weeks,  of  Chelsea,  under  ether,  I  passed  both  electrodes  through  the 


58 


Treatment  of  Uterine  Fibraida  by  Galvanism. 


abdominal  wall  four  inches  each.  Current  five  minutes.  Pulse  normal 
throughout.  Serous  fluid  exuded,  but  not  enough  to  account  for  the  dis- 
appearance of  the  ascites.  It  did  not  reappear  until  just  before  death. 
She  was  calm  and  heroic.  March  27.  Second  application  ;  she  was  feel- 
ing well,  in  good  spirits,  and  able  to  work.  Electrodes  passed  as  before. 
Ten-minute  current.  An  unusual  and  profuse  flow  of  urine,  lasting 
several  days,  with  increased  systemic  disturbance  followed.  Tumour  ap- 
parently arrested.  She  went  through  the  summer  well,  and  demonstrated 
her  improved  health  by  keeping  a  house  full  of  boarders,  doing  all  the 
work  herself.  When  approached  with  reference  to  a  third  operation,  she 
said,  "  I  feel  well  enough,  and  don't  see  why  I  should  go  to  bed  for  two 
or  three  days  simply  to  please  Dr.  Wheeler  and  Dr.  Cutter ;  besides  I  am 
too  busy." 

1876,  March  4,  she  submitted  to  the  third  application.  Six  physicians 
were  present,  among  them  Dr.  S.  G.  Webber,  of  Boston.  Some  had  seen 
her  before,  and  expressed  the  opinion  that  the  tumour  had  diminished  since 
the  last  operation.  Patient  etherized.  Electrodes  were  passed  in  the 
largest  lobe  on  the  right  side  of  the  abdomen.  Five-minute  current. 
The  electrodes  were  then  withdraicn  and  reintroduced  into  another  lobe 
on  the  left  side.  Five-minute  current.  She  was  profoundly  impressed 
with  the  double  application,  but  in  a  few  days  she  was  so  comfortable 
that  it  was  thought  best  to  let  her  alone  for  a  time. 

This  is  the  first  instance  of  four  punctures  made  at  one  operation.  It 
should  not  be  practised  in  any  case  unless  one  is  sure  he  is  dealing  witli  a 
good  subject,  that  is,  one  who  has  borne  the  shock  well,  and  shown  that 
she  is  capable  of  a  profound  impression  without  too  much  systemic  distur- 
bance. During  the  summer  of  1876  she  had  an  attack  of  peritonitis  like 
those  before  the  galvanism.  Dr.  Wheeler  states  that  the  inflammation 
was  situated  away  from  the  site  of  punctures.  No  bad  results  followed, 
and  Mrs.  Peters  continued  in  the  enjoyment  of  good  health  up  to  Oct.  29, 
1876,  the  growth  of  tumour  being  arrested.  On  this  day  she  submitted 
to  the  fourth  application  in  the  presence  of  Prof.  T.  G.  Thomas  and  Dr. 
J.  B.  Hunter,  of  New  York,  Dr.  F.  Semeleder,  of  Mexico,  formerly  a 
Professor  in  Vienna  and  Surgeon-in-Chief  to  Maximilian's  forces  in 
Mexico,  and  Drs.  G.  H.  Bixby,  G.  C.  Gay,  L.  F.  Warner,  and  J.  G. 
Blake,  of  Boston,  Wheeler,  Fenwick,  Haskell,  Shackford,  and  Weeks,  of 
Chelsea,  Sullivan,  of  Maiden.  Marcy  and  Cutter,  of  Cambridge. 

All  interested  examined  and  satisfied  themselves  of  the  character  of  the 
tumour  being  a  subperitoneal,  dense,  and  multilobar  fibroid.  The  pulse 
was  noted  to  be  normal,  the  skin  cool,  and  the  patient  to  be  in  good  con- 
dition for  the  operation.  She  was  etherized.  The  abdomen  was  exposed. 
The  electrodes  were  lubricated  with  olive  oil.  One  was  then  thrust  through 
the  lower  part  of  the  large  ovoid  flattened  lobe  on  the  left  side  of  the 
navel,  from  below  upwards,  to  the  depth  of  four  inches.  The  other  elec- 
trode was  taken  in  the  hand,  the  handle  resting  in  the  palm,  held  against 
the  ball  of  the  thumb  by  the  little,  ring,  and  middle  fingers  of  the  right 
hand,  the  free  edges  of  the  lamina?  being  placed  upwards,  the  index-finger 
pressing  against  the  outer  side  of  the  blade  of  the  electrode  at  about  its 
middle,  the  point  of  the  thumb  also  pressing  against  the  upper  surface  of 
the  flattened  proximal  end  of  the  blade.  This  disposition  of  the  parts  of 
the  hand  giving  a  perfect  control  of  the  instrument,  the  tumour  was 
steadied  by  the  operator's  left  hand,  and  the  second  electrode  was  slowly 
and  continuously  driven  into  the  lobe,  approaching  but  not  touching  the 


1878.]  Treatment  of  Uterine  Fibroids  by  Galvanism. 


59 


Other  electrode.  The  depth  of  penetration  was  four  inches,  so  that  the 
insulated  portion  of  the  electrode  came  within  the  skin.  As  the  second 
conductor  was  attached,  contractions  of  the  abdominal  muscles  demon- 
strated the  passage  of  the  current. 

The  patient  was  watched,  and  as  long  as  there  were  no  symptoms  of 
systemic  disturbance  the  current  was  continued  until  ten  minutes  had 
elapsed.  In  withdrawing  the  electrodes  two  ringers  should  be  placed  close 
to  the  point  of  entrance,  and  hold  the  tissues  in  contact  with  the  tumour 
as  the  instrument  is  withdrawn.  As  the  patient  was  not  apparently  much 
affected,  the  operation  was  immediately  repeated.  One  needle  was  thrust 
into  the  large  lobe  to  the  left  of  the  navel,  and  the  other  into  a  small  lobe 
on  the  right.  The  current  was  continued  for  six  minutes.  The  pulse 
was  accelerated.  She  began  to  look  pale  and  became  restless.  These 
symptoms  were  noticed  as  indicating  the  extent  to  which  the  application 
should  be  carried. 

Oct.  31.  She  was  found  feeling  prostrated.  Bowels  tender  and  sore  ; 
pulse  good.  Still  she  was  dressed  and  sitting  in  a  rocking-chair  by  an 
open  window.    This  was  closed  and  caution  administered. 

Nov.  4.  Was  seen  in  the  act  of  sitting  down  to  a  fish-dinner  she  had 
just  cooked.    Appetite  good. 

Dec.  12.  She  recovered  and  did  well  until  she  moved  her  residence  to 
another  quarter  of  the  city.  Took  cold,  and  injured  herself  by  lifting. 
Constipation,  fever,  pain,  and  tenderness  of  the  belly,  followed  with  loss 
of  sleep  and  appetite*  Dr.  W.  gave  her  castor-oil  and  morphia.  The 
larger  lobe  on  the  left  felt  boggy  and  soft.    No  wave. 

29th.  It  seems  she  attended  a  funeral,  and  stood  on  the  frozen  ground  at 
the  gra  ve  during  the  burial  services.  Now  suffering  much  with  vomiting, 
diarrhoea,  delirium.    Belly  tender  and  sore. 

1877,  Jan.  4.  Reported  better,  but  confined  to  bed. 

17^.  Pain  shooting  down  the  right  side. 

March  28.  Much  better.  Measured  44  inches.  Her  clothes  have  be- 
come at  least  six  inches  looser  than  they  were.    Ready  for  boarders. 

Sept.  18.  Received  a  note  from  Dr.  Wheeler  that  she  died  on  the  16th* 
Four  weeks  previous  had  an  attack  of  dysentery.  This  was  checked,  so 
that  she  was  quite  comfortable.  Peritonitis  followed,  and  death  from  ex- 
haustion. 

Autopsy — Body  much  emaciated.  Peritoneum  firmly  adherent  through- 
out. Oij  ascitic  fluid  removed.  The  fibroids  were  agglomerated  into  an 
irregular  mass  of  a  grayish-white  colour,  mottled ;  in  some  parts  of  the 
colour  of  beefsteak  dotted  with  white  points.  The  whole  appeared  like  a 
mass  of  tallow.  The  lobes  were  joined  as  if  set  in  cement.  Adhesions 
dense  and  tough.  Dissecting  off  the  intestines  the  fibroids  were  found  to 
spring  from  the  uterus,  which  was  lost  in  the  general  mass.  It  appeared 
as  a  cylinder  one  inch  in  diameter,  depth  five  inches.  To  the  right  of 
uterus  a  large  lobe  pointed  downwards  into  the  pelvis.  It  contained  a 
central  cavity  as  large  as  a  walnut,  filled  with  pus.  It  could  not  be  con- 
nected with  the  electrodes.  Above,  on  the  right,  was  an  irregular  lobe 
2  J  inches  in  diameter,  semi-solid,  somewhat  purulent,  penetrated  by  an 
irregular  opening  large  enough  to  admit  the  forefinger.  This  might  have 
been  due  to  the  electrode.  The  largest  lobe  displayed  a  uniform  surface, 
white  and  cartilaginous.  There  were  no  marks  of  the  electrodes  that  had 
repeatedly  penetrated  it.  Coagulated  lymph,  partly  organized,  plastered 
over  the  tumour  and  the  intestines,  which  were  almost  black  and  gangre- 
nous.   Kidneys,  liver,  and  spleen  healthy. 


GO 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


Micrography — The  fluid  with  difficulty  scraped  from  the  cut  surfaces 
of  the  lobes  displayed.  Curling  connective  fibres;  red  blood-corpuscles; 
large  mother-cells ;  other  cells  of  varying  sizes ;  innumerable  granules, 
most  of  them  swarming  with  independent  molecular  motions.  From  the 
density,  the  varying  histological  elements,  and  the  macroscopy,  the  de- 
generation was  probably  cancerous. 

This  case  is  given  at  length  as  its  history  is  complete,  and  it  will  save 
details  in  the  relation  of  the  remaining  cases,  which  must  be  brief. 

Case  XV — Miss  Bridget  C,  single,  24 years  of  age;  patient  of  Dr.  F. 
A.  Howe,  Newburyport.  Dense  fibro-myoma,  pelvic  and  abdominal, 
three  inches  above  the  navel.  Applications,  six.  Present,  Drs.  Graves 
and  Fuller,  of  Lowell.  "  Sure  her  tumour  was  lessened,  because  her 
clothes  were  looser."    Perfect  relief  of  pressure  on  bladder. 

Hemorrhage  uncontrolled,  death  therefrom  a  year  afterwards.  Tumour 
did  not  increase  in  size.  (Reported  in  Boston  Med.  and  Surg.  Joum,, 
Jan.  29,  1874.) 

Case  XVI.— Mrs.  D.,  Marlboro',  Mass.,  1873.  Oct.  15.  Thirty-eight 
years.  Two  children.  Interstitial  fibroid.  Pain.  Hemorrhages.  Bed- 
ridden for  nine  weeks.  Nov.  1.  Five-minute  current.  Chloroform.  Pre- 
sent Dr.  Charles  Putnam,  of  Marlboro',  family  physician.  Dec.  17.  Tu- 
mour diminished  one-third  and  decidedly  softer.  Hemorrhage  checked. 
In  a  week's  time  she  had  been  able  to  ride  out,  and  go  about  the  town  as 
well  as  she  ever  did.  Second  application.  Galvanism  for  the  third  time 
Feb.,  1874.  Tumour  still  diminishing.  An  unusual  effect  was  noticed  at 
this  operation,  namely,  a  sudden  gush  of  blood  from  the  uterus.  It 
ceased  in  a  few  minutes.  Two  years  afterwards  tumour  regained  its 
size.    She  was  in  good  health  at  last  accounts. 

Case  XVII  1 873.  Mrs.  Allen,  of  Marlboro',  Mass.  AVidow.  Forty- 
three  years.  Three  children.  Large  interstitial  fibroid,  irregular,  press- 
ing on  the  rectum.  Very  pale  and  languid  from  loss  of  blood.  Menor- 
rhagia excessive  for  years.  Persistent  and  uncontrollable  hemorrhage 
between  menses.  Chloroform.  Operations.  Urine  very  abundant,  chills, 
fever,  thirst,  pulse  120.  Tumour  reduced  one-half.  Meno-  and  metror- 
rhagia checked.    Health  restored. 

Case  XVIII — Miss  D.,  Fisherville,  N.  H.  Single.  Forty-three 
years  of  age.  Growth  very  solid.  Size  giving  the  idea  of  a  six  months' 
pregnancy.  Pelvis  packed.  Hemorrhages  frequent  and  exhaustive.  Dis- 
abled. 1874,  Feb.  18.  Chloroform.  Current  ten  minutes.  No  pain. 
Two  days  after  tumour  seemed  soft.  Aspirated.  Got  bloody  serum. 
Second  application  Feb.  26,  1874,  followed  by  hemorrhages.  Went  to 
Concord,  N.  H.  Hemorrhages  ceased  after  return  home  in  April,  but 
prostration  continued.  Discharges  of  fetid  matter  from  the  uterus. 
Sometime  after  death  ensued,  and  an  autopsy  proved  it  to  be  a  case  of 
cancerous  degeneration. 

Case  XIX. — Mrs.  Clemena  B.,  Bridgewater,  Mass.  Fifty-three  years 
old.  October  15,  1874.  Childless  marriage.  Anasarca  and  ascites. 
Alarming  metrorrhagia.  Galvanism  five  minutes.  Large  multilobar  of 
six  years'  standing.  After  first  operation  effusions  were  dissipated.  She 
could  sleep  comfortably  in  bed.  Tumour  arrested.  Four  more  operations 
May  28,  and  physical  examination  showed  the  tumour  sensibly  reduced 
after  the  exhibitions.    Health  improved  with  control  of  hemorrhages. 

Case  XX  Mrs.  R.,  Lancaster,  Mass.    Forty  years.    Long  married, 

but  childless.    Interstitial  fibroid  existed  five  years,  seriously  affecting 


1878.]  Treatment  of  Uterine  Fibroids  by  Galvanism.  61 


general  health.  First  application  Nov.  10,  1874.  No  bad  effects.  Ke- 
turned  home,  and  came  back  to  Lowell  for  more.  Bore  them  well  and 
again  went  home.  March  27,  1875,  she  submitted  again.  Tumour  sensi- 
bly diminished.    General  health  decidedly  improved. 

Cask  XXI. — Miss  F.,  of  Newburyport.  Dr.  Howe's  patient.  Treated 
Nov.,  1874.  Age  thirty-eight.  House  servant.  Single.  Tumour  six 
years'  standing.  Enormous  growth.  Cervix  nodular.  Disabled.  Exces- 
sive and  frequent  metrorrhagias.  Losing  ground.  Flowing  bears  no  re- 
lation to  menstruation.  Feeble  and  emaciated.  Forty-eight  hours  after 
first  application  a  second  was  made  followed  by  swelling  of  right  lower 
limb.  The  third  time  free  bleeding  from  one  puncture.  Eight  applications 
in  eight  months.  Reduction  of  tumour  one-half.  Nodules  removed. 
Hemorrhages  stopped.  Patient  reported  herself  lately.  Tumour  still 
diminished.    Feels  very  well. 

Cask  XXII  Mrs.  W.,  Portsmouth,  N.  H.    Widow.   January,  1875. 

Age  fifty.  One  child.  Feeble  health.  Small  fibroid  tumours  of  several 
years'  standing.  Notwithstanding  the  small  size  the  inconvenience  has 
been  very  great.  A  sense  of  pressing  down  preventing  her  from  inclining 
forward  her  body.  Five  operations.  March  27,  reports  marked  relief. 
Able  to  stoop,  bend  forward,  and  tie  her  shoes,  also  to  sit  erect  in  her 
chair,  all  of  which  she  could  not  do  before.  For  two  years  previous  she 
had  been  unable  to  walk  any  considerable  distance.  Now  she  walks  easily 
without  suffering.  General  health  improved.  Tumour  diminished  some- 
what. 

Cask  XXIII. — Miss  ■.   Age  thirty-four.    Gentlewoman.  Patient 

of  Dr.  Luce  Falmouth,  Mass.  1874,  Dec.  3.  Small  tumour  has  existed 
two  years.  Discomfort  considerable.  Battery  applied.  No  bad  effect. 
Dec  5th  second  operation.  30th  another  operation.  1875,  April  16, 
fourth  application.  Health  improved.  May  5th  application.  June  16th 
one  electrode  through  vagina.  Tumour  diminished.  At  last  accounts  it 
had  increased  again.    Patient  on  active  duty  in  a  school. 

Case  XXIV  Mrs.  S.    Patient  of  Dr.  W.  W.  Jewett,  of  Chaumont, 

N.  Y.  1874,  June  4.  Forty-eight  years  of  age.  Several  children.  Not 
much  hemorrhage.  Large  fibroid  multilobar.  Growths  increased  one- 
third  during  the  last  six  months.  Galvanism  this  day.  June  6th  again. 
She  returned  home  with  her  physician  provided  with  means  to  perform 
the  operation.  1875,  Dec.  14,  he  writes:  "  She  has  had  electricity  eleven 
times,  the  tumour  has  reduced  one-half  in  size.  At  the  tenth  operation  I 
aspirated  sixteen  ounces  of  fluid  from  the  upper  part  of  the  tumour."  .... 

Case  XXV  Miss  Phoda  B.  Ellis,  West  Hanover,  Mass.  Large 

fibroid.  April,  1873.  Forty-three  years  of  age.  Constitution  impaired 
by  loss  of  blood.  Had  undergone  much  treatment  in  vain.  Feb.,  1874, 
chloroformed  and  operated  on.  Later  another,  and  followed  by  still  more 
operations — all  without  avail.  However,  she  writes  Sept.  13,  1876:  "For 
the  last  six  weeks  I  have  been  improving,  and  the  tumour  has  very  remark- 
ably diminished.  It  is  very  sudden  and  unexpected,  but  so  certain  has 
been  the  decrease  that  I  could  not  forbear  telling  you  of  it."     .     .     .  . 

Case  XXVI. — Mrs.  John  L.,  Woburn,  Mass.  Thirty-eight  years.  No 
children.  Noticed  enlargement  three  or  four  years  ago.  Naturally  a 
brunette.  Very  hard  lobed  abdominal  and  pelvic  tumour  with  irregular 
surface.  The  series  of  applications  produced  vomiting  and  marked  suffer- 
ing. The  patient  was  pronounced  incurable,  and  a  malignant  case.  1877, 
March  28.    Condition  terrible.    Great  and  constant  abdominal  pain  only 


02 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


[July 


relieved  by  large  doses  of  morphia.    Constant  vomiting.    In  bed.  States 

that  tumour  has  not  inereased  in  size.    Now  it  is  soft  and  fluctuating  

before  it  was  hard  and  gritty.  No  hemorrhage.  Measurement  thirty- 
six  inches.  With  Dr.  Kimball's  knowledge  and  consent  I  supplied  her 
with  my  carbon  and  zinc  battery  ten  pairs  of  plates,  six  inches  by  one 
inch,  one-fourth  and  one-eighth  inch  thick.  The  fluid  the  same  as  de- 
scribed. Arrangement  my  own.  Electrodes  consisted  of  copper  disks 
one  and  one-half  inch  in  diameter,  one-eighth  inch  thick.  Advised  St. 
Leon  spring  water  for  constipation. 

April  12.  Has  faithfully  used  the  battery.  Measurement  thirty-two 
and  one-eighth  inches.  Morphia  disused,  because  the  pain  was  so  much 
abated.    Tumour  harder  and  smaller. 

21th.  Has  vomited  but  once  or  twice  since  the  battery  was  applied. 
Measures  thirty  inches.    Feels  better. 

May  5.  Battery  two  hours  daily.  Thirty  inches.  Dr.  W.  S.  Brown, 
of  Stoneham,  and  Moore,  of  Weburn,  saw  her. 

13th.  Thirty-one  inches.    Been  out  doors. 

July  10.  Thirty-one  inches.    Diarrhoea.    Mouth  sore.    Tongue  clean. 
Severe  chills.    Abdominal  pain  not  returned. 
August.  Discouraged.    I  gave  up  treatment. 
Sept.  Improved.    Oct.  She  died.    No  autopsy. 

The  diminution  in  size  and  abolition  of  pain  were  sufficient  rewards  for 
the  pains  taken  for  her  relief.  The  new  battery  spoken  of  certainly  did 
well.  It  is  quite  portable,  and  is  a  good  galvano-caustic  battery,  and  it 
may  and  has  answered  tor  tin's  operation. 

Case  XXVII — Miss  Eliza  C,  single,  40  year-  ;  tumour  very  hard, 
8  inches  in  diameter;  existed  since  1872.  Three  operations  followed  by 
an  arrest  of  development  for  about  two  years  ;  increase  again  ;  able  to 
walk  or  stand  without  pain,  which  was  impossible  before  operation  ;  gene- 
ral health  good  ;  now  on  diet  treatment. 

Case  XXVIII — Mrs.  B.,  35  years  ;  married  for  several  years,  no 
children.  June,  1874,  sent  by  Dr.  W.  L.  Atlee,  of  Philadelphia,  for  gal- 
vanism ;  very  large  interstitial  fibro-cystic  uterine  growth.  An  abscess 
discharged  a  saucerful  daily  by  several  openings  in  the  hypogastrium,  and 
was  connected  with  the  peritoneal  cavity.  Ten  quarts  of  ascitic  fluid  were 
removed  by  tapping;  next  day  battery  applied  ten  minutes:  three  days 
afterwards  it  was  applied  again.  In  July  was  again  opera: ed  on  ;  went  to 
Nantucket  and  remained  through  the  summer.  September  went  to  Lowell ; 
tapped;  next  day  galvanism  ;  the  day  after  returned  home  ;  live  applica- 
tions ;  tumour  arrested.  Patient  insists  on  her  improvement ;  menses 
regular. 

Her  physician,  Dr.  F.  A.  Paddock,  of  Pittsfield,  Mass.,  writes : 
"  Nov.  30th,  Dec.  4th,  18th,  and  29th  operations:  she  was  able  to  be  out 
of  the  bed  nearly  every  day  throughout  the  winter ;  she  gradually  failed 
till  May  1st,  when  she  expired.  Autopsy.  Peritoneal  cavity  obliterated  ; 
fistula  communicated  with  intestinal  portion  of  abdomen  ;  the  anterior 
portion  was  filled  with  gelatinous  cysts,  with  here  and  there  serous  cysts  ; 
behind  was  the  uterus  enlarged  to  the  4th  month  size.  A  large  gelatinous 
cyst,  filled  with  straw-coloured  serous  fluid,  16-17  quarts,  appeared  to 
be  connected  with  the  right  side  of  the  uterus  ;  ovaries  obliterated  ;  it  was 
not  an  encouraging  case  for  galvanism." 

Case  XXIX  Miss  Eliza  C,  Salem,  Mass.,  school-teacher,  43  years 

of  age  ;  had  tumour  for  several  years  ;  resembled  a  pregnant  woman  at  full 


1878.] 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


63 


term.  March  2, 1874.  Frequent  and  profuse  hemorrhages  ;  had  given  up 
hope  of  resuming  her  profession.  March  3.  Chloroform  and  ten-minute 
current.  March  11.  Second  application;  afterwards  several  times,  with 
such  relief  that  in  April  she  resumed  her  school ;  the  pain  recurred  ; 
tumour  evidently  diminished;  one  application  of  galvanism  removed  per- 
manently the  pain.  Subsequently  the  tumour  diminished  so  much  that  an 
uninterested  observer  could  detect  no  enlargement  without  palpation. 

Cam-:  XXX  Mrs.  N.  L.  Ellis,  widow,  38  years  of  age;  Feb.  26th, 

1875.  Trouble  began  in  1869  with  hemorrhages  ;  anaemic  ;  os  uteri  reminds 
of  incipient  cancer  ;  three  applications,  apparently  without  result.  1877, 
Aug.  "21.  Measures  36  inches;  tumour  soft  and  fluctuating ;  sound  pene- 
trated the  uterus  7  inches.  A  small  battery,  described  in  Case  XXXVI. , 
was  employed.  26th.  35  inches.  31st.  34  inches.  Sept.  8th.  Putting  on 
flesh,  36^  inches.  10th.  Tumour  evidently  fluctuating  on  pressure  from 
fundus  to  pubis.  14th.  Appetite  ravenous.  25th.  34-1-  inches.  28th. 
Dr.  Kimball  pronounced  the  tumour  decidedly  diminished  in  size ;  in 
progress.  Diet. 

Case  XXXI  Mrs.  C,  Dubuque,  Iowa,  42  years  of  age;  an  invalid 

on  account  of  a  large  fibroid.  Dr.  Washington  L.  Atlee,  of  Philadelphia, 
sent  her  to  Dr.  Kimball  for  the  purpose  of  trying  galvanism.  It  was 
dense  and  involved  pretty  much  the  whole  uterus ;  increasing  rapidly. 
Dec.  4th,  1874.  Battery  applied.  Dec.  9th.  Second  trial;  patient  and 
friends  insist  that  the  tumour  has  diminished  ;  nineteen  applications  were 
made  at  intervals  of  about  one  week  each,  when  she  returned  home. 
Lately  her  sister  reported  her  as  attending  to  her  duties  as  well  as  ever — 
tumour  much  diminished.  It  was  added  that  she  thought  it  was  a  duty  to 
pursue  this  line  of  treatment  judging  from  the  success  in  this  case. 

Case  XXXII  1873.,  'Dec.  18th.     Mrs.  N.  E.  C,  Woburn,  21 

years  of  age  ;  married  2-J  years,  no  children  ;  interstitial  fibroid,  central, 
dense,  rising  beyond  the  navel  ;  blanched  from  hemorrhages ;  unfitted  for 
employment  ;  present  Dr.  Wolgamott,  then  of  Woburn.  Current  four 
minutes  under  chloroform ;  in  the  course  of  a  few  days  she  declared  the 
tumour  diminished. 

Feb.  18,  1874.  Tumour  softer  and  elastic  ;  reduced  one-half  in  size  ; 
second  operation  ;  electrodes  evidently  penetrated  a  cavity  containing  gas 
or  fluid  pus,  as  pus  has  escaped  through  the  punctures  by  the  electrodes. 

May  31.  The  writer  applied  the  battery ;  there  was  the  same  feeling  ot 
a  central  cavity.  June  6th.  Another  profound  effect ;  owing  to  her  hus- 
band's increasing  debility  operations  were  suspended.  June,  1875.  Health 
good  and  tumour  still  lessened  one-half  ;  menses  normal  ;  no  hemorrhages. 

Dec.  19,  1876.  Calls  her  health  excellent. 

1877,  Aug.  21.  Tumour  increased ;  distinct;  fluctuating;  pain  severe  ; 
profuse  menses  ;  gave  chlorodynes,  gallic  acid  ;  strict  animal  diet. 

1878,  Jan.  Much  improved  ;  tumour  lessened.    In  progress. 

Case  XXXIII  Miss  Lucetta  T.,  Stoneham,  Mass.,  dressmaker, 

aged  40  years  ;  large  multilobar  fibroid  ;  fifteen  years'  existence ;  tumour 
rose  beyond  the  umbilicus ;  dysmenorrhoea  and  menorrhagia ;  excessive 
pain  in  left  hypogastrium  every  night,  often  required  professional  assist- 
ance ;  frequent  micturition  ;  her  hold  upon  life  was  weak.  Dr.  William 
F.  Stevens,  of  Stoneham,  Mass.,  called  my  attention  to  her  July  28th, 
1874.  Having  made  her  will  she  submitted  to  the  galvanism.  Aug.  4th. 
Repeated.    Relieved  at  once  of  pressure. 

Nov.  24,  1874.  Her  clothes  show  two  inches  less  size.  Abdominal 


64 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


[July 


cramps,  to  which  she  has  been  subject  for  twenty  years,  have  disappeared  ; 
menses  painless ;  sleep  continuous ;  can  lie  on  left  side,  which  was  impos- 
sible before  ;  is  working  more  than  ever  before.  Two  more  operations ; 
effect  of  the  last  quite  severe. 

July,  187G.  Went  to  the  Centennial ;  thence  she  visited  the  West. 
Rode  over  rough  roads  in  springless  wagons,  suffering  no  inconvenience. 
Now  enjoys  good  health.    Tumour  diminished  now  one-third. 

Case  XXXIV — 1875,  March  2.  Mrs.  Kate  R.,  Dexter.  Me.,  4."*  years 
of  age.  Large  abdominal,  trilobed  fibro-myoid  existed  at  least  eight 
years.  Reduced  very  much  by  hemorrhages ;  pallid  countenance  and 
waxy  look;  disabled  and  dependent.  Battery  applied.  Present  Urs. 
Wheeler,  Shackford,  and  Weeks,  of  Chelsea.  On  March  2,~>  she  measured 
32  and  34  inches.  Operation  renewed.  April  2d,  another.  She  returned 
home  and  maintained  herself. 

1877,  Jan.  4.  Tumour  increased  and  bad  symptoms  returned.  Strongly 
urges  the  removal  by  section.  17th,  another  application.  It  was  pro- 
found in  its  effects.  Oct.  18th.  Health  excellent.  Thought  the  tumour 
diminished  once  more. 

Case  XXXV — Miss  Eliza  K.,  East  Boston,  June  19, 1876,  4  1  years  of 
age.  Had  large  multilobar,  very  dense  fibro-myoid  tumour  ten  years. 
Abdominal,  increasing  dysmenorrhea,  menorrhagia,  pressure  and  gnawing 
sensations;  general  health  poor ;  30£  inches  measurement.  Sept.  16. 
Third  operation  ;  the  venerable  Dr.  P.  M.  Crane,  of  East  Boston,  pre- 
sent ;  29  inches.  1876,  Jan.  G.  Seventh  and  last.  Resistance  like  that 
of  cheese.  Electrodes  within  half  an  inch  of  each  other.  The  blood 
that  flowed  out  on  the  groove  of  the  carbon  electrode  coagulated  into  a  firm 
clot.  Drs.  D.  F.  Lincoln  and  E.  Chenery  present.  A  few  days  later 
there  was  a  deep  furrow  in  the  tumour,  running  in  the  track  of  t lie 
needles.  Tumour  diminished  and  softened;  hemorrhage  checked ;  health 
improved. 

Case  XXXVI  Miss  C,  44  years  of  age.  Oct.  30,  1875.  Pelvic 

and  abdominal  fibro-myoid  had  existed  a  year  or  more  ;  stony,  hard, 
multilobar.  July,  1876.  Present  Drs.  F.  A.  Sawyer  and  L.  H.  Luce. 
Galvanism  applied  as  above  ;  electrodes  in  rectum  and  abdomen  ;  current 
used  too  long ;  still  constipation  was  relieved ;  lies  all  night  in  bed  ;  dis- 
tress "  low  down"  relieved  ;  sleep  unbroken  ;  both  hands  peeled  of  epi- 
dermis. Nov.  27.  Daily  chills  and  fever.  Abdomen  distended  with  a 
large  fluctuating  tumour.  Felt  in  vagina ;  estimated  that  the  pelvic  tu- 
mour had  diminished  at  least  one-half.  Dec.  1.  Aspirated  Oj  of  purulent 
chocolate-coloured  fluid.  Severe  distress,  syncope,  and  fainting  followed. 
2d.  A  ten-celled  battery,  copper  and  zinc,  A\  inches  by  2  inches,  was  put 
into  three  hours'  daily  use,  per  cutan  for  months.  8th.  Dr.  Kimball  saw 
her  ;  thought  the  cyst  might  be  ovarian  ;  prognosis  decidedly  bad.  She 
continued  to  improve.  1877,  Jan.  25.  Battery  causes  pain,  and  is  dis- 
used. Feb.  3.  Cyst  enlarged.  4th.  Capillary  matter  passed  via  rectum  ; 
colour  same  as  the  aspirated  fluid;  odour  that  of  rotten  eggs  ;  tumour  les- 
sened immediately.  March  14.  Feels  very  much  better.  April  28.  Tu- 
mour still  lessened.  May  8.  St.  Leon  spring  water  a  success.  Sept.  22. 
Pelvic  portion  increased.    1878,  April  30.  Quite  well. 

Case  XXXVII  1876,  Nov.  3.    Mrs.  S.,  Chelsea,  Dr.  Wheeler's 

patient,  a  woman  of  small  stature ;  small,  hard,  multilobar  fibro-myoid ; 
painful  and  tender ;  menorrhagia,  anaemia.  At  the  operation  blood  clot 
was  found  on  the  carbon  electrode.    Pulse  regular  throughout.  Present, 


1878.]  Treatment  of  Uterine  Fibroids  by  Galvanism. 


05 


Drs.  G.  Kimball,  S.  W.  Abbott,  of  Wakefield ;  Hanscom,  of  Somerville ; 
Wheeler  and  Pratt,  of  Chelsea.  25th.  Free  from  pain,  and  feels  as  well 
as  ever  she  did.  Tumour  unchanged.  Dec.  6.  Inspection  and  palpation 
confirm  her  statement  that  she  is  smaller.  1877,  Jan.  4.  Another  appli- 
cation.   At  last  accounts  doing  well. 

Case  XXXVIII  Miss  Caroline  A.  D.,  Marlboro',  Mass.    Dec.  29, 

1870.  47  years  old.  Menorrhagia  always.  Tumour  existed  four  years  at 
least.  Lobe  in  right  groin  large  as  an  orange  ;  uterus  distended  ;  os  annu- 
lar ;  tumour  dense.  This  day  galvanism  three  minutes  ;  one  electrode  in 
vagina,  one  in  abdomen.  Present  Drs.  Kimball,  Bixby,  Hanscom,  of 
Somerville,  and  F.  F.  Brown,  of  Reading.  1877,  March  20.  Abdom- 
inal lobe  disappeared.  There  is  now  a  cervix  uteri  three-fourths  of  an 
inch  in  length.  Sept.  11.  Cervix  shorter  than  it  was  ;  no  sign  of  abdom- 
inal portion.    Doing  well  at  last  accounts. 

Case  XXXIX. —1877,  Feb.  4.  Mrs.  Cook,  Groveland,  Mass.  Dense 
mobile  abdominal  fibroid,  "large  as  a  child's  head."  Four  or  five  months 
pregnant.  Pain  and  distress.  Four  applications  ;  pain  relieved  ;  fibroid 
diminished.  At  full  term  she  was  delivered  of  a  living  child!  This  is 
the  boldest  procedure  in  these  cases.  It  was  performed  on  the  ground 
that  abortion  would  occur  at  any  rate. 

Case  XL  1877.  April  4.  Mrs.  Whitworth,  Lowell,  Mass.  Abdom- 
inal pelvic,  interstitial,  solid  fibroid  tumour  of  the  uterus,  seven  inches  in 
diameter.  She  submitted  to  several  applications  of  the  battery  in  the 
usual  way.  She  thought  the  tumour  diminished.  This,  however,  is  cer- 
tain, that,  whereas  she  was  a  terrible  sufferer  requiring  nearly  constant 
medical  attendance  for  relief,  now  she  is  as  well  as  ever  she  was. 

Case  XLI — Mrs.  E.  L.  P.,  patient  of  Dr.  C.  W.  Hackett,  of  Maplewood. 
1877,  April  13,  35  years  of  age  ;  married  14  years  ;  childless.  Oct.  1875 
measured  21  inches;  1877,  April  19,  32  inches.  Nervous  system  com- 
pletely deranged.  Bed-ridden  eighteen  months.  Hyperesthesia  and  va- 
ginismus ;  fainting,  with  defecation.  Examined  under  ether.  A  trilobed 
dense  growth  attached  to  and  incorporated  with  the  posterior  uterine  wall, 
size  of  fist.  Uterine  cavity  four  inches  deep.  Both  electrodes  introduced 
through  the  rectum.  Three-minute  current  ;  application  followed  by 
ambulation,  painless  defecation.  May  3.  Tumour  apparently  smaller. 
22d.  About  the  house.  Sept.  6.  Another  operation.  Tumour  appeared 
smaller  ;  it  was  soft  and  easily  penetrated.  Present  Drs.  Sullivan,  of  Mai- 
den ;  Bean,  of  Medford  ;  and  Hackett,  of  Brookline.  Bad  symptoms  re- 
curred, though  another  operation  was  practised. 

Case  XLII — 1877,  Aug.  23.  Miss  S.,  24  years,  vertical  tumour.  Dec. 
187G.  Dr.  Wheeler,  of  Chelsea,  saw  her,  with  her  physician,  Dr.  French, 
of  Maiden.  Large  interstitial,  sub-serous  multilobar  fibroid.  Tumour 
packs  the  pelvis  ;  os  dilated  ;  per  rectum  large  and  spongy ;  pain  chief 
cause  of  complaint.  Present  Drs.  Vanderveer  and  W.  H.  Bailey,  of  Al- 
bany, N.  Y. ;  Wheeler  and  Weeks,  of  Chelesa  ;  French,  of  Maiden  ;  and 
Hackett,  of  Maplewood.  Electrodes  through  abdomen  and  rectum.  It 
should  be  stated  that  Dr.  Wheeler  had  previously  introduced  small  insu- 
lated needles  connected  with  my  small  battery,  with  the  result  of  reducing 
the  oedema  of  vagina  and  pelvis.  Sept.  0.  He  made  a  similar  applica- 
tion. Oct.  15.  The  writer,  in  presence  of  others,  made  another  deep  ap- 
plication. Doing  well  at  last  accounts.  Tumour  diminished,  and  pain 
dissipated. 

No.  CLI  July  1878.  5 


66 


Treatment  of  Uterine  Fibroids  by  Galvanism. 


[July 


Case  XLIII — 1877,  Oct.  23.  Patient  of  Dr.  C.  W.  Stevens,  North 
Cambridge,  Mass.,  and  turned  over  to  the  writer  by  Dr.  Kimball.  Mary 
S.,  colored,  servant,  43  years  of  age.  Confined  to  bed  since  Aug.  8,  1*77, 
on  account  of  pain  and  weakness.  Large  abdominal  pelvic  and  intersti- 
tial fibro-myoid.  Tumour  increasing  in  spite  of  ergotine.  Dr.  Stevens 
etherized,  and  Drs.  Hildreth,  of  Cambridge,  and  Dorr,  of  Medford,  as- 
sisted. Current  ran  4^  minutes.  Nov.  3.  Dr.  S.  says  she  has  suffered 
very  much.  Right  leg  and  thigh  look  "  like  a  milk-leg."  This  had  been 
so  before  the  operation.  All  insist  the  tumour  is  smaller.  5th.  Abdomen 
diminished  from  34  to  29  inches.  Swelling  on  right  leg  subsided.  Left 
leg  swelled  with  its  venae  comites.  Profound  shock  after  operation.  Dee. 
21.  Considerable  discharge  from  rectum  of  detritus.  March,  1*7*.  Pain 
and  hemorrhage  abolished.  Disuse  of  morphia.  Failing.  April.  1878. 
Doing  some  housework.    Removed  to  British  provinces. 

IV.  Cases  Relieved  by  the  Operation. 

Case  XLIV — 1874,  Oct.  12.  Mrs.  F. ;  no  children  ;  33  years  of  age. 
Tumour  increasing  rapidly  in  size  for  the  last  two  months.  Suffered  from 
pain  and  distension  all  the  time,  but  intensely  for  four  or  five  days  before 
the  menses.  Four  operations;  no  impression  on  the  tumour.  The  pain 
and  suffering  were  relieved. 

Case  XLV  Mrs.  Pollock,  Worcester,  40  years  old;  no  children.  A 

hard  movable  fibroid  occupied  the  pelvis  and  extended  up  to  the  umbilicus. 
Frequent  hemorrhages  ;  prostration  and  disability.  The  symptoms  were 
relieved,  but  the  tumour  was  not  affected  by  several  profound  applications 
of  the  battery. 

Case  XL VI  Nov.  25,  1876.  Mrs.  H.,  coloured,  55  years  ;  one  child. 

Large  multilobar  fibroid  of  fifteen  years'  standing,  dense  and  increasing. 
"  Has  bled  like  an  ox."  Now  running  down  very  fast.  Ascites,  cauli- 
flower ulceration  of  os  uteri,  profuse  hemorrhages,  debility,  calcareous 
degeneration.  In  bed  three  weeks.  Impression  on  writer  was  that  of 
malignancy.  Dr.  H.  0.  Marcy,  of  Cambridge,  her  physician,  decidedly 
thought  not.  In  the  presence  of  him,  Drs.  Holt,  Clarke,  and  Edgerly,  of 
Cambridge,  galvanism  was  applied  for  only  three  minutes.  Nov.  27. 
Found  the  patient  getting  out  of  bed.  Ascites  gone  ;  vaginal  flooding 
ceased.  Dec.  13.  Says  the  operation  has  done  her  "lots  of  good."  Is 
half-dressed  in  bed.  1877,  Jan.  3.  Repeated  operation.  9th.  Says  she 
should  be  up  and  about  if  it  was  not  such  very  cold  weather.  Feb.  1G. 
Fistulas  at  both  punctures.  No  pain  or  discomfort.  Patient  about  the 
house  doing  work.  Great  appetite.  No  vaginal  hemorrhages.  March 
14.  Fistulas  closed.  Up  and  dressed.  No  ascites.  Ten  days  ago 
hemorrhage  relieved  by  injection  of  warm  water.  27th.  More  hemor- 
rhages. May  3.  Drs.  F.  M.  Dearborne,  U.  S.  N.,  Lawton,  of  Spring- 
field., Mass.,  and  Marcy,  present.  One  electrode  readily  penetrated  the 
lower  lobe  ;  the  other  was  directed  into  the  uppermost  lobe.  It  struck  a 
substance  solid  like  a  stone.  Force  was  used.  It  slipped,  made  exit 
through  the  skin,  and  penetrated  the  left  middle  finger  of  the  writer.  The 
lobe  was  calcareously  degenerated.  Another  lobe  lower  down  was  more 
readily  penetrated.  8th.  Sitting  and  sewing  in  bed.  Suffered  much  after 
operation.  Husband  refuses  to  have  any  more  interference.  Punctures 
healed.  Death  from  recurrence  of  bad  symptoms  occurred  within  six 
months.  It  is  proper  to  add  that  Dr.  Marcy  came  in  at  last  with  the  idea 
of  malignancy. 


1878.]  Treatment  of  Uterine  Fibroids  by  Galvanism. 


67 


V.  Cases  Cured  by  the  Operation. 

Case  XLVII. — Miss  Fitts,  of  Haverhill,  Mass.,  34  years  of  age.  April 
22,  1873.  Had  a  large  globular  and  movable  fibroid.  She  had  given  up, 
and  "  had  gotten  through  with  all  the  pangs  of  death."  Recent  increase 
in  size  and  suffering.  Chloroform  ;  three-minute  current.  June  23.  An- 
other application  by  the  writer;  five-minute.  Present,  Drs.  Jas.  R. 
Xichols  and  Chase,  of  Haverhill.  Aug.  22.  Last  application  by  the 
writer.  Present,  Dr.  Wm.  Cogswell,  of  Bradford.  Gradual  diminution 
of  tumour.  Oct.  1.  It  has  nearly  disappeared.  Afterwards  it  entirely 
disappeared,  and  remains  so.  (Reported  in  Boston  Med.  and  Surg. 
Jburn.j  Jan  29,  1874.)    Health  restored. 

Case  XLVIII  1874,  Oct.  17.     Mrs.  C,  23  years  of  age.  Patient 

of  Dr.  Wm.  Coggswell,  of  Bradford,  Mass.  Constant  suffering  from  uri- 
nary incontinence,  requiring  a  forcible  pressure  over  pubis  at  each  evacua- 
tion of  the  bladder.  Tumour,  interstitial  and  uterine,  packed  the  vagina. 
Drs.  Howe  and  Towle  present.  Chloroform.  Both  electrodes  through 
the  vagina.  Nov.  3.  Condition  very  satisfactory.  Able  to  rest  most  of 
the  night  without  being  obliged  to  get  up.  Examination  showed  a  dim- 
inution of  tumour  one-half.  Instead  of  the  peculiar  hardness  of  a  fibroid 
the  diseased  organ  had  become  quite  soft  and  flabby.  Operation  the 
second.  Six  weeks  later  the  third  operation  took  place.  Patient  able  to 
visit  neighbours  on  foot  without  difficulty.  Subsequently  the  tumour  en- 
tirely disappeared.  Sad  to  say,  health  was  not  restored.  It  is  reported 
she  did  not  receive  proper  care  and  nursing,  became  bed-ridden,  and  died 
from  exhaustion.  As  far  as  the  galvanism  was  concerned,  it  was  gratifying. 

Case  XLIX  1875,  July  14.  Mrs.  Huse,  Manchester,  N.  H.,  child- 
less, 40  years  of  age.  Fibro-cystic  may  be  fibro-ovarian  tumour.  After 
several  applications  it  gradually  disappeared.  Subsequently  it  reappeared. 
Twice  she  submitted  again  to  galvanism.  On  proceeding  to  operate  the 
third  time  no  evidence  whatever  was  found  of  the  existence  of  the  tumour. 
Jan.  30,  1877.    General  health  still  good.    Tumour  has  not  reappeared. 

Case  L  Mrs.  Peebles,  Manchester,  N.  H.,  36  years  of  age.   "  Tumour 

hardish  and  punky,  and  as  large  as  a  bowl."  Unwell  twice  a  month. 
Gave  her  two  applications  of  galvanism,  with  an  interval  of  three  days. 
Current  five  minutes  each ;  made  a  tremendous  impression,  causing  severe 
pain,  vomiting,  and  prostration.  First  application  was  through  the  ab- 
dominal walls  ;  the  second  through  the  vagina.  Before  the  first  operation 
the  uterine  neck  could  not  be  found,  but  the  finger  came  into  contact  with 
the  fibroid.  Tumour  had  diminished  one-half.  She  could  cross  her  lower 
limbs,  which  she  could  not  do  before.  Oct.  1877.  Some  time  after  Dr. 
Kimball  saw  her  incidentally,  and  found  the  tumour  had  entirely  disap- 
peared. 

Tremoxt  Temple,  Boston,  Mass.,  May,  1873. 


G8 


Harris,  The  Operation  of  Gastro-Hysterotomy.  [July 


Article  IV. 

The  Operation  of  Gastro-Hysterotomy  (True  Cesarean  Section) 
Viewed  in  the  Light  of  American  Experience  and  Success,  with 
a  Record  of  Cases  Largely  obtained  by  Correspondence.  liy 
Robert  P.  Harris,  M.D.,  Member  of  the  Am.  Philos.  Soc.  ;  Fellow  of  Coll. 
of  Physicians,  Philadelphia;  Member  of  Philadelphia  Obstetrical  Soc,  etc. 

Having  largely  increased  our  collection  of  American  Csesarean  case-, 
since  the  appearance  of  the  April  number  of  this  Journal,  we  continue  the 
report  as  then  contemplated,  and  present  a  new,  and,  in  some  respects,  re- 
markable statistical  series,  covering  almost  the  entire  period  embraced  by 
the  first  record,  and  necessarily  changing  or  modifying  the  general  result,  as 
to  relative  mortality,  proportion  of  operations  under  exhaustion,  etc.  Ad- 
ditional information  which  we  have  since  received  renders  it  necessary,  in 
order  to  be  accurate,  to  make  certain  corrections  and  additions  to  reports 
of  former  cases,  which  will  be  found  at  the  close  of  this  paper. 

The  Multiple  Cesarean  case  reported  by  Dr.  Nancrede  in  1 835,  a  Myth. 
— In  Dr.  Nancrede's  report  of  the  first  Gibson  operation,1  we  find  the  fol- 
lowing : — 

"  Finally,  a  friend  of  great  intelligence  and  respectability,  holding  a  respectable 
official  position  in  Louisiana,  now  on  a  visit  to  this  city,  mentions  as  a  fact,  that 
the  operation  has  been  repeatedly  and  successfully  performedin  that  country,  but 
more  especially  within  the  last  ten  years,  several  times  by  Dr.  Prevost,  of 
Donaldson ville,  Louisiana.  My  informant  also  states,  that  he  was  in  the  house 
on  one  occasion,  while  Dr.  P.  was  performing  the  operation  on  a  mulatto  woman, 
for  the  sixth  or  seventh  time,  which,  however,  terminated  fatally,  though  it  had 
been  successful  on  the  same  patient  several  times  before." 

Finding  that  Dr.  Nancrede  never  hunted  up  the  record  of  this  very 
remarkable  case,  and  that  there  was  no  report  of  it  in  any  French  or  Ameri- 
can journal  of  the  period,  we  began  to  hold  the  story  in  very  great  doubt, 
and  determined,  if  possible,  to  clear  up  the  mystery,  although  it  may  be 
imagined  that  the  task  undertaken  was  no  simple  one.  It  took  several 
years  before  we  could  find  a  physician  in  Ascension  Parish,  who  would  act 
for  us  in  making  a  local  search  among  old  inhabitants  ;  but  at  last  in  Dr. 
John  E.  Duffel,  whose  grandfather  had  been  a  contemporary  of  Dr.  Prevost, 
was  found  an  active  and  interested  co-worker.  Through  him  we  were  also 
enabled  to  find  Dr.  Thomas  Cottman,  the  successor  of  Dr.  Prevost,  now 
resident  in  New  York,  whose  information  has  been  of  much  value.  It 
would  be  easy  to  fill  several  pages  of  this  Journal  with  the  correspondence 
and  interviews  relating  to  this  one  case,  which  are  both  curious  and  inte- 
resting; but  it  will  be  sufficient  to  state  the  conclusions  arrived  at,  with- 
out giving  all  the  points  in  the  testimony. 

There  were  no  multiple  series  of  operations  as  stated,  but  there  was  a 
woman  at  Donaldsonville  upon  whom  Dr.  Prevost  did  operate  once,  and 


1  Am.  Journ.  Med.  Sci.,  1835,  vol.  xvi.  p.  347. 


1878.]       Harris,  The  Operation  of  Gastro-Hysterotomy. 


69 


whose  case,  by  some  unaccountable  process,  became  the  basis  of  a  plantation 
rumor,  that  she  had  been  under  the  knife  in  the  same  Avay,  no  less  than 
seven  times.  This  tradition  is  still  current  among  old  coloured  people,  but 
with  this  difference  from  the  account  given  to  Dr.  Nancrede  by  his  friend  ; 
the  woman  did  not  die  after  the  seventh  operation,  but  lived,  and  her  child 
also,  this  being  the  only  occasion  in  which  any  of  her  children  lived.  Now 
for  the  facts  of  the  case,  viz.  : — 

No.  73,  1831.  Dr.  Francois  Prevost,  operator,  Donaldsonville,  Ascen- 
sion Parish,  Louisiana.  Communicated  by  Dr.  Thomas  Cottman,  of  New 
York,  formerly  of  Donaldsonville  ;  aided  by  important  local  investigations 
made  under  Dr.  John  E.  Duffel,  of  the  same  locality. 

Caroline,  black,  aged  about  "29  or  30,  slave  of  Madame  Cadet  Maurons, 
of  Donaldsonville,  in  second  labour ;  first  child  a  male,  believed,  from  all 
accounts,  to  have  been  delivered  by  craniotomy,  and  perhaps  evisceration  ; 
from  which  we  infer  that  she  had  a  pelvis  deformed  by  rickets,  a  very 
common  disease  in  this  part  of  the  State.  The  incision  was  made  in  the 
left  side  of  the  abdomen,  and  a  female  child  removed,  to  which  he  gave  the 
name  of  "  Cesarinne,"  and  stipulated  that  if  it  lived,  it  should  be  made 
free.  The  child  was  a  mulatto,  lived,  and  was  given  its  freedom,  grew  up, 
married,  and  is  believed  to  be  living  now  in  New  Orleans.  Caroline  made 
a  good  recovery,  and  lived  until  her  daughter  grew  up.  She  was  not  a 
mulatto,  but  black,  pretty  stout,  and  is  described  as  "  always  walking- 
straight." 

Dr.  Cottman  first  saw  her  in  1832,  when  her  child  was  about  a  year 
ohl,  and  examined  the  cicatrix  in  the  side  of  her  abdomen.  She  and  her 
child  were  frequently  seen  by  him  and  other  witnesses  at  various  times  in 
after  life.  The  sister  of  Caroline's  mistress  is  still  living,  and  is  positive 
that  the  woman  had  but  the  two  children  mentioned.  Two  slaves,  for- 
merly the  property  of  Dr.  Prevost,  told  separately  the  current  traditional 
story  about  Caroline  having  been  opened  seven  times,  and  one  said  that 
she  had  a  child  all  cut  to  pieces  in  removal. 

The  informant  of  Dr.  Nancrede  probably  received  his  impression 
through  the  prevalent  belief.  As  Dr.  Prevost  was  a  graduate  of  the  school 
of  Paris,  it  is  quite  certain  that  he  would  have  reported  or  talked  about 
such  a  remarkable  series  of1  operations  as  was  related  by  Dr.  Nancrede 
forty-three  years  ago,  as  there  is  no  satisfactorily  authenticated  case  like 
it  on  record. 

Francois  Prevost,  D.  M.  P.,  was  born  about  the  year  1764,  at  Pont-de- 
Ce,  in  the  south  of  France  ;  graduated  at  Paris  ;  settled  in  St.  Domingo  ; 
was  driven  out  by  the  revolution  under  Toussaint  POuverture,  escaped  to 
the  French  colony  of  "  Louisianne,"  and  there  died  in  1842,  of  a  partial 
paralysis  of  several  years'  standing,  at  the  age  of  78.  He  was  therefore 
about  67  years  old,  when  he  operated  on  Caroline  Bellan  (or  Bellack), 
which  was  no  doubt  his  last  Cesarean  case.  In  1832,  he  retired  from 
much  of  his  general  practice,  in  favor  of  Dr.  Thomas  Cottman,  to  whom 
he  subsequently  left  his  instruments  and  library,  and  devoted  his  attention 
more  particularly  to  gynaecology. 

Donaldsonville  appears  to  have  been  a  centre  of  French  medicine  and 


70 


Harris,  The  Operation  of  Gastro-Hysterotomy. 


[July 


surgery  in  the  days  of  Dr.  Prevost,  two  of  his  contemporaries,  St.  Martin 
and  Gourrier,  both  good  surgeons,  having  been  with  Napoleon  to  Moscow  ; 
besides  whom  there  were  Bouszoin,  considered  as  at  the  head  of  his  pro- 
fession ;  Tusson,  Daboral,  Arboneaux,  Preval,  Edward  Duffel,  Clements, 
etc. 

Dr.  Cottman  says  that  Dr.  Prevost  pointed  out  to  him  in  1832,  a  little 
boy,  six  or  seven  years  old,  that  he  said  he  had  brought  into  the  world  by 
the  Cesarean  section.  The  boy  was  then  living  in  the  town,  with  a 
woman  who  kept  a  small  shop,  and  as  Dr.  Cottman  never  saw  his  mother, 
it  is  probable  that  she  died.  He  believes  that  she  was  the  property  of  a 
German  blacksmith  by  the  name  of  Krohn.  The  boy  lived  to  grow  up, 
and  was  still  alive  a  few  years  ago,  having  removed  to  Washington  where 
lie  may  be  now. 

Dr.  Cottman,  in  letters  of  March  26th  and  April  17th  inst.,  refers  to 
two  Ca\sarean  operations  performed  by  Dr.  Prevost  on  the  same  woman, 
witli  success  to  her  and  both  children.  He  says,  "  I  entertain  no  doubt 
of  the  fact,  though  it  be  not  to  my  personal  knowledge  ;  he  was  univer- 
sally credited  with  it.  .  .  .  the  operation  was  not  deemed  of  great 
import  in  that  day  and  locality  of  bold  surgery  and  considerable  scien- 
tific merit  and  attainment."  He  has  more  recently  in  person  stated  that 
the  testimony  was  not  traditional,  and  came  in  such  a  way  that  there 
could  be  no  question  of  its  truth. 

We  have  been  thus  particular  in  matters  of  history,  because  we  stated 
in  the  American  Journal  of  Obstetrics  that  Louisiana  was  the  pioneer  in 
gastro-hysterotomy  in  this  country;  "that  the  operation  was  performed  a 
number  of  times  with  success  in  the  early  part  of  this  century"  prior  to 
any  of  the  cases  we  then  reported;  and  that  the  said  State  had  probably 
furnished  a  large  proportion  of  the  Cesarean  operations  of  the  United 
States. 

As  the  country  around  Donaldson  ville,  including  the  town,  reports  8  cases, 
and  the  rest  of  the  State  7,  it  is  probable  that  a  full  record  would  show  a 
large  number  of  operations,  and  a  remarkable  proportion  of  successes. 
As  far  as  ascertained,  we  compute  the  cases  at  15,  with  a  saving  of  11 
women  and  9  children. 

Xo.  74,  1832 — Dr.  Thomas  Cottman.  Ascension  Parish,  Louisiana, 
operator.  Communicated  by  him  March  28th,  1878.  Woman  black, 
aged  20,  slave  of  Mrs.  Stansbury,  and  in  labour  50  hours.  "Patsey"  was 
first  under  the  care  of  Drs.  Thompson  and  Tusson,  who  tried  to  deliver 
her  with  the  crotchet,  but  such  was  the  deformity  of  the  pelvis  that  the 
plan  was  abandoned,  and  Dr.  Cottman  called  in  to  perform  the  Cesarean 
operation.  The  child  was  now  dead,  and  the  woman  much  exhausted  by 
the  pain  and  fatigue  of  the  long  labour,  but  made  a  good  recovery.  Dr. 
Tusson  is  said  to  have  sent  a  report  of  the  case  to  a  medical  journal  in 
Montpellier,  France.  The  operation  was  performed  in  October,  and  the 
woman  was  alive  in  1850;  incision  made  in  the  linea  alba.  Dr.  Cottman 
was  also  the  operator  in  1849  upon  case  No.  20  of  our  tabular  record,  and 
the  woman,  who  was  living  in  1862,  he  thinks  may  still  be  alive. 

Xo.  75,  1857  Florence,  Alabama.  Dr.  James  W.  Stewart,  operator; 

communicated  by  him  March  4,  1878.    We  give  this  report  more  in 


1878.]       Harris,  The  Operation  of  Gastro- Hysterotomy.  71 


detail,  as  an  example  of  the  kind  of  eases  that  so  often  escape  collection 
at  the  hand  of  a  statistician,  who  is  satisfied  with  giving  simply  published 
records,  and  is  content  to  base  his  calculations  of  success  and  failure 
thereon. 

Dr.  Stewart  operated  with  success  in  1860,  and  reported  the  case,  but 
like  many  others,  did  not  place  on  record  the  unsuccessful  one,  because  it 
did  him  no  special  credit,  although  no  discredit  could  attach  to  him  for 
having  failed  to  save  the  woman  ;  this  properly  belonging  to  the  delaying 
accoucheur.  We  honor  Dr.  Stewart  and  many  other  surgeons  for  their 
prompt  action  in  aiding  us  to  present  the  records  of  their  unsuccessful 
work,  as  these  are  quite  as  important  in  giving  instruction  as  their  oppo- 
sites.  We  gain  knowledge  from  bad  cases  as  well  as  good ;  thus  obtain- 
ing success  by  avoidance  as  much  as  imitation.  The  object  of  this  paper 
is  not  simply  to  show  how  many  women  and  children  have  been  saved, 
and  how  many  lost,  but  to  demonstrate  the  difference  between  the  results 
of  early  and  late  operations.  When  we  compare  one  case  with  another, 
the  very  natural  inquiry  arises,  Why  was  this  woman  saved  ?  or,  Why  was 
she  lost?  as  the  case  maybe.  Compare  Dr.  Gibson's  operations  with 
Dr.  Stewart's,  and  we  can  easily  see  that  the  action  of  the  accoucheurs 
had  much  to  do  with  the  success  of  the  first,  and  failure  of  the  second. 
The  great  wonder  is,  that  cases  like  Dr.  Stewart's  in  1860,  should  ever 
succeed. 

The  subject  of  Dr.  Stewart's  operation  in  September,  1857,  was  a  col- 
oured woman  of  19,  a  stout,  healthy  primipara,  well  formed,  with  the 
exception  of  a  contracted  pelvis,  having  a  conjugate  diameter  of  1^  inches. 
Gestation  complete,  pains  strong  and  regular  for  48  hours.  Patient  began 
to  show  signs  of  exhaustion,  sick  stomach,  faintness  when  in  a  sitting 
position,  pulse  small,  and  beating  120  per  minute.  This  state  of  things 
continued  for  24  hours  longer,  when  Dr.  Stewart  was  sent  for  by  the  at- 
tending accoucheur  with  a  request  to  bring  his  instruments  for  an  opera- 
tion.   Craniotomy  had  not  been  performed. 

Dr.  Stewart  found  the  woman  in  so  exhausted  a  condition  after  72  hours 
of  labor,  that  he  unhesitatingly  pronounced  the  case  as  hopeless  for  the 
mother,  and  as  the  long-continued  pressure  had  evidently  destroyed  the 
child,  there  was  nothing  to  hope  for  from  an  operation.  At  the  urgent 
request  of  the  physician  and  friends,  Dr.  S.  operated.  There  was  but 
little  loss  of  blood ;  but  notwithstanding  the  use  of  frictions,  artificial 
warmth,  and  stimulants,  no  reaction  took  place,  and  the  woman  died  in 
10  hours.  Dr.  Stewart,  in  closing  his  letter,  says  :  "  My  decided  opinion 
is,  that  had  the  operation  been  performed  at  an  earlier  period,  the  patient 
might  have  been  saved."  What  possible  reason  could  an  accoucheur  give 
for  delay  in  a  case  with  a  conjugate  diameter  of  one  inch  and  a  quarter  ? 
With  such  a  measurement  there  ought  to  be  no  difficulty  in  deciding  what 
is  to  be  done,  and  at  once,  as  there  is  only  one  thing  that  can  be  done,  to 
save  the  life  of  the  mother,  child,  or  both. 

No.  76,  1859  Dr.  J.   C.  Thompson,  South  Bloomfield,  Franklin 

County,  Ohio,  operator.  Mrs.  S.,  aged  32,  strong  and  muscular,  and  in 
labour  for  the  third  time.  Was  affected  with  recto-vaginal  fistula,  and 
extensive  vaginal  adhesions,  almost  occluding  the  passage,  the  lower  part 


72 


Harris,  The  Operation  of  Gastro-Hysterotomy. 


of  the  rectum  having  sloughed  off,  and  the  upper  being  connected  with 
the  vagina,  which  served  as  its  outlet.  This  fearful  condition  resulted 
from  a  labour  three  years  before,  in  which  twelve  boms  were  consumed  in 
cutting  up  and  extracting  the  foetus.  The  woman  had  been  in  labour 
about  a  day  ("from  one  day  until  the  next")  when  Dr.  Thompson  oper- 
ated, and  her  pulse,  after  being  dressed,  was  1 15.  She  made  a  good  re- 
covery, but  the  child,  which  was  hand-fed,  died  in  a  week,  being  affected 
with  sore  mouth,  and  irritable  stomach  and  bowels,  possibly  somewhat 
due  to  its  being  in  the  month  of  July.  (Transactions,  Ohio  State  Med. 
Soc,  I860,  p.  63.) 

No.  77,  18G0  New  York  City,  Dr.  T.  Gaillard  Thomas,  operator. 

Case  communicated  by  him,  1878.  White  woman,  aged  28,  afflicted  with 
puerperal  convulsions,  coming  on  near  full  term,  and  continuing  about  6 
hours  before  Dr.  Thomas  saw  her.  Patient  became  moribund  after  twelfth 
or  thirteenth  convulsion  ;  did  not  rally,  and  died  before  operation  was 
ended.  Child  removed,  dead,  as  a  consequence  of  the  convulsions  in  its 
mother. 

No.  78,  Jan.  1866 — Ascension  Parish,  Louisiana,  Dr.  Beauville  Cla- 
verie,  operator.  Communicated  through  Dr.  John  E.  Duffel,  of  Donald- 
sonville,  La.,  1878.  Felicie,  black,  about  30  years  old,  deformed  and 
very  lame,  primipara.  Called  in  when  she  was  in  extremis  from  long 
labour.  Child  probably  dead  for  several  hours.  CVsarean  operation  per- 
formed early  in  the  morning.  Foetus  a  large  male.  Woman  died  of 
shock  in  a  few  hours,  having  never  rallied  in  the  least  alter  the  operation. 

No.  79,  Nov.  1867 — New  York  City,  Dr.  Thomas  C.  Finnell,  opera- 
tor. Communicated  by  him,  1878.  Subject,  a  German  primipara,  aged 
26,  with  a  contracted  pelvis,  from  an  exostosis  near  the  promontory  of  the 
sacrum.  Conjugate  diameter  2  inches.  Woman  under  care  of  an  ac- 
coucheur, and  in  labour  3  days,  when  Dr.  Finnell  was  called  in.  Child, 
a  male,  lived,  and  was  given  the  name  of  "  Macduff."  Mother  died  in  48 
hours,  of  exhaustion. 

No.  80,  1868  New  York  City,  Dr.  Thomas  C.  Finnell,  operator. 

Communicated,  1878.  Subject  also  a  German  primipara,  with  a  bony 
tumor  filling  the  cavity  of  the  sacrum.  Woman  under  two  accoucheurs  ; 
in  labour  3  days.  Child  removed,  dead,  having  perished  from  uterine 
pressure.    Mother  died  of  exhaustion  in  48  hours. 

N,o.  81,  1869  New  York  City,  Dr.  Thomas  C.  Finnell,  operator. 

Communicated,  1878.  Coloured  girl,  ret.  16,  in  labour  4  days  ;  two  ac- 
coucheurs in  attendance  ;  second  in  consultation.  Dr.  F.  summoned  to 
perform  Caesarean  operation.  Found  her  almost  pulseless.  Child  dead  on 
removal.    Woman  died  in  24  hours,  from  hemorrhage  and  exhaustion. 

Autopsy  about  24  hours  after  death.  About  eight  ounces  of  blood 
found  in  peritoneal  cavity.  Antero-posterior  diameter  of  the  superior 
strait  1|-  inches ;  transverse  and  oblique  3|.  Pelvis  preserved  in  Belle vue 
Medical  Museum.  No  uterine  sutures  employed  in  any  of  Dr.  Finnell's 
three  operations.  They  were  all  performed  in  the  lower  part  of  the  city, 
hi  Thompson,  Cherry,  and  Mulberry  streets. 

No.  82,  June,  1871  Ligonier,  Indiana,  Dr.  D.  AY.  C.  Denny,  opera- 
tor. Woman  white,  primipara,  wife  of  a  farmer,  and  married  twelve 
years;  short  and  thickset,  weighing  about  140.  Congenital  occlusion  of 
vagina  partially  relieved  after  marriage  by  a  surgical  operation.  Was 
advised  early  in  her  pregnancy  to  submit  to  the  induction  of  abortion,  to 
avoid  the  necessity  of  performing  the  Cesarean  section  ;  but  declined,  say- 
ing she  would  "run  all  risks." 


1878.]       Harris,  The  Operation  of  Gastro-Hysterotomy. 


73 


Dr.  Denny  called  in  on  morning  of  27th  ;  pains  regular  and  unusually 
strong  until  3  P.  M.,  when  membranes  ruptured.  Pains  checked  for  the 
night  at  10  P.  M.,  by  morphia,  but  returned  actively  at  6  A.  M.,  when  a 
convulsion  of  several  minutes  took  place.  Gastra-hysterotomy  soon  per- 
formed ;  no  more  eclampsia ;  foetus  well  developed,  and  weighing  9 
pounds  ;  dead  from  uterine  pressure  ;  top  of  head  coniform  for  about  two 
inches  in  length. 

Pulse  of  woman  good  for  3  days,  when  she  was  found  to  be  rapidly 
sinking,  and  in  a  few  hours  died.  "  Her  bed,  bedding,  and  personal  ap- 
parel had  been  scrupulously  changed  by  officious  female  friends,  contrary 
to  imperative  orders  and  earnest  entreaties"  of  both  the  physicians  in  at- 
tendance. She  is  reported  as  not  having  had  an  alarming  symptom  before 
this,  and  Dr.  Denny  attributed  her  death  to  the  "  kind  meddlesome  inter- 
ference of  neighbors."  [Indiana  Jour,  of  Med.,  vol.  ii.,  Nov.  1871,  p. 
310.) 

No.  83,  1872. — South  Bethlehem,  Pennsylvania,  Dr.  Abram  Stout, 
operator.  Communicated  by-  him,  1878.  Subject  a  white  woman,  wife 
of  Patrick  B.,  about  30  or  35  years  of  age,  with  contracted  pelvis  ;  in 
labour  two  days,  and  under  care  of  several  physicians.  Was  much  ex- 
hausted when  Dr.  Stout  was  called  in.  Child  dead  before  operation. 
Not  much  blood  lost.  Woman  stimulated,  and  fed  with  beef-tea,  but 
died  of  exhaustion  in  a  few  hours.  Dr.  Stout  repeats  the  often  written 
regret  of  our  surgeons,  that  he  had  not  been  called  much  earlier. 

No.  84,  1874. — New  York  City,  Dr.  T.  Gaillard  Thomas,  operator. 
Mrs.  M.,  white,  wife  of  a  labourer,  about  30,  mother  of  five  children;  last 
two  labours  complicated,  one  by  prolapsed  funis,  and  the  other  by  arm  pre- 
sentation. Existence  of  uterine  fibroid  diagnosed  several  months  before  by 
Dr.  Thomas,  and  woman  warned  of  the  danger  of  pregnancy,  and  urged 
to  report  at  once  to  her  physician  if  it  occurred,  which  she  failed  to  do,  as 
he  was  not  summoned  until  she  was  in  labour. 

Had  been  several  hours  in  labour  when  Dr.  Thomas  was  called,  and 
waters  evacuated  5-|  hours  ;  pains  becoming  feeble  ;  funis  hanging  cold 
and  pulseless  between  patient's  thighs.  Child  dead  some  time.  Pulse  and 
temperature  of  woman  good.  Large,  hard,  fibrous  tumour  found  attached 
low  down  along  posterior  and  lateral  walls  of  lower  segment  of  uterus, 
closing  cervix  except  anteriorly.  Version  and  crainotomy  found  imprac- 
ticable. Caesarean  section  practised  as  a  last  resort.  Uterine  incision 
closed  by  silver-wire  sutures. 

Child  removed  in  30  minutes  ;  patient  dressed  and  in  bed  in  20 ;  did 
well  for  24  hours,  when  violent  peritonitis  set  in,  and  she  died  in  3  days 
after  the  operation.  {Am.  Jour,  of  Obstetrics,  New  York,  v.  viii.,  Feb. 
1876,  p.  612.) 

No.  85,  1874 — New  Haven,  Kentucky,  Dr.  J.  N.  McCormack,  ope- 
rator. Mrs.  M.  O'D.,  white,  44,  fifth  child,  in  labour  fifteen  days,  thirteen 
of  them  under  a  midwife.  During  first  week  a  young  physician  who  was 
called  in  gave  it  as  his  opinion  that  she  was  not  in  labour.  Dr.  McC. 
found  her  much  exhausted,  with  anxious  countenance,  feeble  and  fre- 
quent pulse,  distended  and  tender  abdomen,  and  some  feeble  labour  pains. 
He  found  a  hard  and  immovable  fibroid  tumour  in  the  lower  posterior 
portion  of  the  neck  of  the  uterus  occluding  the  superior  strait,  except  a 
small  space  in  right  anterior  region,  where  finger  could  be  passed  to  head 
of  child,  which  was  in  a  state  of  advanced  decomposition.  Craniotomy 
found  impracticable.    Abdominal  section  revealed  a  peritoneum  covered 


74 


Harris,  The  Operation  of  Gastro-Hysterotomy.  [July 


Avith  recent  lymph.  Some  hemorrhage  from  uterine  vessels,  but  easily 
controlled.  Woman  rallied  and  appeared  to  do  well  for  a  few  hours,  then 
sank  rapidly,  and  died  in  twenty-six  hours  from  operation.  She  had  suf- 
fered from  indefinite  uterine  symptoms  from  the  time  of  her  last  confine- 
ment, which  increased  in  intensity  as  her  pregnancy  advanced. 

This  case  is  one  of  peculiar  interest,  as  the  fibroid  tumour  was  in  the 
most  favourable  locality  for  the  uterine  incision  to  be  made  with  advan- 
tage. All  fibroid  Cesarean  cases  in  our  country  have  been  fatal,  except 
No.  50,  which  was  a  pelvic  growth;  but  this  one  of  Dr.  McCormack 
might  possibly  have  been  saved  if  the  labour  had  existed  but  a  few  hours 
when  the  section  was  made   (American  Practitioner,  Dec.  1874,  ]>.  341.) 

No.  .86,  Jan,  31,  187"). — Lancaster,  Pennsylvania,  Dr.  William  R. 
Grove  operator.  Hannah  Lavegan,  about  ;5<»,  and  a  deformed  dwarf, 
some  three  feet  in  height,  with  a  curved  spine.  Child  presented  by  right 
hip,  which  became  impacted  by  delay,  so  that  it  could  not  be  turned,  or 
brought  through  the  pelvis  with  the  blunt  hook,  after  three  hours'  effort. 
Labour  commenced  on  Jan.  28th;  membranes  ruptured  at  10  A.M.; 
woman  up  and  about  the  hospital  (Lancaster  County)  ward  next  day; 
pains  renewed  early  on  30th ;  ceased  making  efforts  to  deliver  per  mat 
nuturales  at  halt-past  two  A.M.  of  31st.  Woman  in  delicate  health,  and 
exhausted  by  an  irregular  labour  of  three  and  a  half  days;  operated  on  at 
half-past  two  P.  M.  of  31st  ;  foetus  a  female,  which,  alter  much  effort,  was 
resuscitated,  and  lived;  it  was  well  formed  and  healthy.  The  woman 
died  of  exhaustion  on  February  2d.  fifty-one  hours  after  the  operation. 
Conjugate  diameter  found  by  autopsy  to  measure  three  inches,  and  trans- 
verse rive  inches.  (Med.  Sf  Surg.  Reporter.  Phila.,  vol.  xxxii.,  1875, 
p.  298.) 

No.  87.  1875 — New  Haven.  Connecticut,  Dr.  Francis  Bacon,  operator. 
Communicated  1878  by  Prof.  Stephen  G.  Hubbard,  M.D.,  of  Yale  Col- 
lege. Woman  colored,  primipara,  2<*>,  rachitic  in  childhood,  conjugate 
diameter  an  inch  and  a  half,  breech  presentation.  In  labour  several  days, 
feeble,  exhausted,  and  pulse  136  at  time  of  operation,  child  dead.  Woman 
died  in  fifty-live  hours,  as  might  have  been  expected  after  so  long  delay. 
Autopsy  revealed  the  existence  of  pus  in  the  uterine  incision,  but  no  evi- 
dence of  peritonitis. 

No.  88,  1877  Cincinnati,  Ohio.  Dr.  George  E.  Walton,  operator. 

White  girl,  19,  deformed  from  coxalgia,  weight  78  pound.?,  open  abscess 
in  groin,  bad  cough,  diarrhoea,  and  living  in  a  low,  miserable  part  of  the 
city.  Conjugate  diameter  2-^,  transverse  3^-,  right  pelvic  wall  straight. 
Forceps  used  with  strong  traction,  but  without  avail;  Cesarean  operation 
chosen  over  craniotomy,  because  considered  the  less  dangerous  in  her 
feeble  state  of  health.  Labour  well  advanced  when  operation  was  per- 
formed ;  child  removed  alive  and  quite  vigorous ;  free  hemorrhage  from 
lower  edges  of  uterine  wound  for  a  few  minutes ;  one  silver  wire  suture 
inserted  in  middle  of  incision.  Woman  almost  died  on  the  table,  but 
revived  after  operation  and  lived  fifteen  days.  Died  of  exhaustion  from 
general  condition  of  health  and  want  of  proper  attention.  Child  died  in 
two  days.   (The  Clinic,  Feb.  23d,  1878,  p.  85.) 

No.  89,  1878  Dr.  Roland  G.  Curtin,  Philadelphia,  operator.  Report 

read  by  him  before  Philadelphia  Obstetrical  Society,  March  7th,  1878. 
Woman  black,  20,  a  rachitic  dwarf,  but  in  good  health,  pelvis  deformed ; 
conjugate  diameter  2  inches,  transverse  3 \.  Dr.  Curtin  not  called  until 
labour  had  existed  eighteen  hours ;  operation  at  State  Hospital  Feb.  8th, 


1878.]       Harris,  The  Operation  of  Gastro-Hysterotomy. 


75 


after  twenty-four  hours  of  labour;  condition  considered  as  good,  and  mem- 
branes still  unruptured.  Considerable  hemorrhage  took  place  from  the 
lower  part  of  the  uterine  wound.  Seven  carbolized  catgut  sutures  were 
inserted  in  the  uterus  to  close  the  incision  and  arrest  the  hemorrhage, 
which  were  tied  in  treble  knots.  Pulse  84  an  hour  and  a  half  after  the 
operation.  The  hemorrhage  having  been  soon  controlled  by  the  sutures, 
there  was  not  much  blood  lost  from  the  operation.  Woman  had  scarcely 
any  pain,  and  no  vomiting;  died  on  seventh  day. 

Autopsy  twelve  hours  after  death.  Wounds  unhealed,  except  outer 
part  of  abdominal,  slightly;  uterine  wound  open,  and  of  a  gangrenous  ap- 
pearance; slight  peritonitis:  a  well-formed,  dense,  fibrinous  clot  found  in 
the  heart. 

This  is  the  fourth  time  the  Cesarean  operation  has  been  performed  in 
Philadelphia,  and  the  eighth,  as  far  as  known,  in  this  State.  It  is  the 
fifteenth  in  this  country  in  which  the  uterus  has  been  sewed  up,  and  the 
first  in  which  the  sutures  were  of  carbolized  catgut,  or  any  animal  tissue, 
carbolized  or  plain.  Deer-sinew  ligatures  were  for  forty  years  a  favourite 
with  the  late  Dr.  Paul  F.  Eve,  of  Nashville ;  but  they  were  used  to  secure 
arteries,  and  not  to  sew  up  wounds.  The  objection  to  animal  sutures  is  that 
the  knots  are  very  insecure,  becoming  untied  before  union  can  take  place. 

The  revival  of  the  use  of  the  uterine  suture,  as  far  as  we  have  been 
able  to  ascertain,  appears  to  have  been  due  in  great  measure  to  the  suc- 
cess of  Dr.  Godfroy,  of  Mayence,  who,  on  March  27th,  1840,  sewed  up 
the  uterus  of  a  woman  who  had  been  two  days  in  labour,  by  means  of 
common  needles  and  double  waxed  thread.  For  this  act  he  was  much 
condemned  by  his  contemporaries ;  but  the  recovery  of  the  woman  recom- 
mended the  innovation,  and  influenced  others  to  imitate  him. 

We  regard  the  use  of  uterine  sutures  as  still  in  a  measure  experimental, 
and  are  not  prepared  to  say  that  the  danger  is  never  increased  by  them. 
We  are,  however,  satisfied  of  their  value  in  cases  of  atony  of  the  uterus 
after  prolonged  labour,  and  of  hemorrhage  from  the  cut  sinuses;  they 
also  secure  the  uterus  against  leakage,  resulting  from  post-partum  relaxa- 
tion of  the  organ  reopening  the  wound.  There  have  not  been  cases 
enough  to  test  the  relative  success  of  operations  with  and  without  sutures; 
but  the  largely  increased  resort  to  them  shows  that  the  profession  at  home 
and  abroad  is  inclined  to  regard  the  method  with  decided  favour. 

In  looking  over  the  records  of  old  operations,  in  which  success  was  in 
some  instances  very  remarkable,  we  are  inclined  to  ask  what  we  have 
gained  in  the  prevention  or  arrest  of  peritoneal  inflammation  since  we 
abandoned  the  use  of  the  lancet ;  and  also  Avhat  has  been  effected  by  anaes- 
thesia, when  we  have  to  contend  against  an  increased  tendency  to  vomit- 
ing, and  inertia  of  the  uterus. 

One  thing  is  certain,  the  relative  mortality  has  decidedly  increased  in 
the  last  twenty  years  over  what  it  was  prior  to  that  time.  In  the  early 
days  of  this  operation  in  the  United  States,  fully  one-third  of  the  cases 


76  Harris,  The  Operation  of  Gastro- Hysterotomy.  [July 


were  delivered  on  the  first  day  of  labour;  but  in  the  last  twenty  years 
timely  operations  have  been  much  more  rarely  performed,  the  proportion 
being  about  one  in  eight  or  nine.  We  are  most  unaccountably  retro- 
grading in  this  respect,  and  losing  by  delay  what  possibly  we  have  gained 
in  improved  methods  of  operating  and  treatment;  for,  if  anything  has 
been  satisfactorily  demonstrated  by  our  researches,  it  is  the  vital  impor- 
tance of  an  early  resort  to  the  knife,  if  it  is  to  be  used  at  all,  with  a  rea- 
sonable hope  of  success. 

A  very  careful  examination  of  the  whole  subject  satisfies  us  that,  in  the 
great  majority  of  cases,  the  operation  should  be  performed  in  a  few  hours 
after  labour  has  commenced,  or  as  soon  as  the  uterus  is  sufficiently  dilated 
to  admit  of  the  discharges  having  a  ready  exit  after  delivery.  Taking  the 
operations  of  Gibson,  Scudday,  Nettles,  Merinar,  McLelland,  and  New- 
ton as  types,  we  should  say  that  a  labour  of  six  to  twelve  hours  should  be 
long  enough  as  a  general  rule,  if  we  hope  to  save  both  mother  and  child, 
which  should  be  our  aim  in  the  operation,  if  at  all  possible. 

Cases  75  and  84  are  fair  examples  of  the  folly  of  delay  which  is  so  often 
fatal  to  women  affected  with  deformed  pelves.  The  stupidity  of  waiting 
hours,  and  even  days,  for  a  woman  to  accomplish  anything  for  herself, 
with  a  conjugate  of  1^  or  1^  inches,  almost  exceeds  belief.  No.  75  is 
particularly  well  marked  as  a  case  of  unaccountable  waiting  for  nature, 
with  nothing  to  gain  by  it.  For  an  ignorant  plantation  midwife  to  do  this 
is  not  so  much  to  be  wondered  at,  for  we  have  seen  her  counterpart  in  this 
city  wait  four  days  before  calling  in  a  physician ;  but  for  a  graduate  in 
medicine,  with  any  pretension  to  knowledge,  to  do  the  same  thing,  and 
particularly  in  a  large  city  where  surgeons  abound,  is  unaccountable  in 
the  extreme ;  such  accoucheurs  should  quit  the  profession  for  the  good  of 
the  community. 

It  is  very  unfortunate  for  the  class  of  women  most  subject  to  pelvic  de- 
formities, that  they  should  so  often  fall  into  the  hands  of  ignorant  mid- 
wives,  or  physicians  of  an  inferior  grade,  when  they  require  for  their 
management  the  best  talent  of  the  land ;  if  this  was  not  the  case,  the 
Ccesarean  operation  would  have  been  more  frequent  and  successful  than 
our  statistics  indicate.  We  recognize  the  danger  of  this  form  of  delivery, 
but  are  not  at  all  willing  to  measure  the  risk  by  the  general  result  of  all 
cases  early  and  late,  when  we  can  show  the  special  advantages  of  the 
former. 

We  have  now  presented  reliable  records  of  89  operations  of  all  grades, 
with  a  saving  of  38  women  ;  and  44  children  delivered  alive,  of  whom  38 
were  still  living  after  some  time.  We  have  heard  through  correspondents 
of  seven  more  cases,  but  satisfactory  particulars  have  not  yet  reached  us, 
except  as  to  the  results  to  mother  and  child.  The  whole  collectively 
would  number  96  operations,  with  a  saving  of  43f  per  cent,  of  the  women 
and  children. 


1878.]       Hakkis,  The  Operation  of  Gastro- Hysterotomy. 


77 


It  is  hardly  fair  to  charge  upon  the  Cesarean  operation  the  results  that 
have  so  often  followed  it.  We  admit  the  dangers  of  this  form  of  obstetric 
surgery,  but  are  not  willing  to  make  the  operation  answerable  for  the 
faults  of  midwives  and  uneducated  accoucheurs.  When  we  consider  that 
56  women  were  operated  upon  in  a  more  or  less  exhausted  staie  ;  that  3 
were  either  moribund,  or  closely  approaching  it  ;  that  5  were  affected  with 
convulsions  ;  that  only  20  were  in  a  favourable  condition  ;  and  that  the 
tallest  of  11  of  the  89  was  but  four  feet  one  inch  in  height,  Ave  are  only 
amazed  that  so  large  a  proportion  escaped  with  their  lives,  and  are  led  to 
the  very  natural  inquiry,  what  would  have  been  the  result  if  all  these 
women  had  been  operated  upon  early,  and  under  more  favourable  auspices? 

What  is  aided  for  the  future  is,  that  physicians  should  all  be  taught 
that  in  our  own  country  the  records  of  the  past  clearly  set  forthr  that  a 
serifs  of  timely  operations  on  women  in  a  fair  condition  of  health  'will 
sore  from  70  to  lb  per  cent,  of  both  mothers  and  children.  This  was  our 
judgment  six  years  ago,  and  has  not  been  changed  by  an  addition  to  our 
collection  of  cases  of  more  than  50  per  cent,  during  the  interval. 

La  pa  ro-elytrotomy,  as  devised  by  Ritgen,  Physick,  and  BaudeIocquer 
and  recently  revived  by  T.  Gaillard  Thomas,  of  New  York,  and  performed 
with  -uecess  by  him,  and  Alex.  J.  C.  Skene,  of  Brooklyn,,  as  a. substitute 
for  irastro-hvsterotomy,  has  been  attracting  considerable  attention,  parti- 
cularly in  New  York,  where  the  old  operation  has  had  little  to  recommend 
it  on  the  score  of  success,  six  out  of  seven  women  having  died,  and  but 
two  children  being  saved.  By  the  sub-peritoneal  operation,  which  avoids 
wounding  either  the  peritoneum  or  uterus,  much  more  favourable  results 
have  been  obtained ;  three  out  of  five  women  having-  been  saved,  and  all 
of  the  children  but  one  delivered  alive ;  two  subsequently  died. 

It  is  far  from  being  a  simple  operation,  as  the  cases  of  both  operators 
will  show,  for  in  three  of  them  the  bladder  was  opened,  although  much 
care  was  taken  to  prevent  it.  It  requires  much  more  time,  anatomical 
knowledge,  and  surgical  skill,  than  the  Cesarean  section,  and  is  therefore 
not  well  adapted  for  general  practice.  In  large  cities,  where  skill  can  be 
commanded,  and  where  the  disposition  to  delay  appears  to  be  so  common 
on  the  part  of  midwives  and  accoucheurs  attending  cases  of  deformed  pel- 
vis, it  will  be  a  valuable  substitute,  as  proved  by  the  experience  of  New 
York. 

There  have  not  been  as  yet  cases  enough  to  determine  the  full  value  of 
the  operation,  but  it  appears  to  be  much  safer  after  exhaustion  from  long 
labour  than  the  Cesarean  section.  If  surgical  aid  should  be  called  in 
early  in  a  series  of  cases,  and  an  equal  number  of  each  operation  per- 
formed, we  are  not  at  all  inclined  to  believe  that  the  new  method  would 
have  any  marked  advantage  over  the  old  on  the  score  of  safety  to  the 
mothers  and  children.  But  as  women  will  call  in  ignorant  aid,  especially 
among  the  foreign  residents  of  our  large  seaport  towns,  and  delays  will 


78  Harris,  The  Operation  of  Gastro-Hysterotomv.  [July- 


occur,  we  believe  it  would  be  safer  to  operate  upon  them  by  laparo- 
elytrotomy,  so  far  as  we  know  by  the  cases  reported.  We  should  gladly 
hail  any  expedient  which  offers  an  increased  safety  to  the  mother  and 
tends  to  diminish  the  necessity  for  craniotomy.  As  delay  is  begotten  of 
ignorance,  we  are  not  sanguine  enough  to  hope  that  any  improvement  can 
take  place  as  long  as  we  are  unprotected  by  law  against  such  pretenders 
as  abound  in  our  by-streets  and  practice  on  the  credulity  of  the  poor. 

The  experience  of  Philadelphia  has  been  a  remarkable  one  in  case-  of 
abdominal  delivery,  and  would  lead  our  obstetricians  to  favour  the  old 
operation.  All  the  Caesarean  cases  fell  into  the  hand-  of  educated  ac- 
coucheurs ;  all  were  affected  with  deformity  of  the  pelvis  ;  all  were  operated 
upon  before  the  membranes  were  ruptured;  and  all  of  the  children  (4) 
are  now  living.  Two  women  were  lost,  but  neither  from  acute  peritonitis, 
as  before  explained.  Two  women  were  operated  upon  by  Laparotomy 
after  rupture  of  the  uterus,  and  both  were  saved.  Of  nine  Cesarean 
cases  in  the  whole  State,  four  were  favourable  to  the  women. 

In  New  York  State  and  city  there  have  been  thirteen  operations,  and 
eleven  deaths.  Of  the  two  saved,  one  operated  on  herself,  and  the  other 
was  performed  in  good  season.  In  the  last  forty  years  every  operation 
was  fatal;  all  (11)  were  cases  of  delay  but  two,  one  of  which  died  in  the 
operation,  and  the  other  was  the  subject  of  a  large  uterine  fibroid.  This 
gives  for  the  State  a  less  percentage  of  women  saved  than  we  find  in  the 
English  statistics  of  Dr.  Radford. 

In  the  balance  of  the  United  States,  as  far  as  ascertained,  one-half  of 
the  women  have  been  preserved.  Ohio  presents  a  record  of  8  op°rations, 
with  6  recoveries,  all  published;  but  fails  to  find  any  unpublished  cases, 
which  inclines  us  to  believe  that  there  have  been  some  not  recorded  which 
were  possibly  not  so  favourable;  as  in  many  States  diligent  search  ha.  dis- 
covered one  or  more  such.  If  these  are  all,  Ohio  has  a  remarkable  re- 
cord ;  for  of  5  women  operated  upon  in  conditions  of  more  or  less  exhaus- 
tion, 4  lived,  although  but  1  child  was  saved.  The  3  early  cases  saved 
all  the  children  and  2  of  the  women,  the  one  lost  being  a  dwarf  of  3  ft. 
6.  But  for  a  persevering  search,  Louisiana  would  present  8  instead  of  15  ; 
New  York  8  instead  of  13 ;  Alabama  3  instead  of  8 ;  Pennsylvania  7 
instead  of  9,  etc.    We  have  found  in  all  31  unpublished  Caesarean  cases. 

The  Martinique  cases,  given  on  page  334,  last  number,  resulted  favour- 
ably to  the  children,  as  was  supposed.  Mad.  Hachard  was  25  at  first 
operation;  had  been  the  subject  of  rickets,  and  measured  3  ft.  10,  in 
height ;  conjugate  diameter  computed  at  1^-  in.  Operations  performed  in 
good  season. 

General  result  North  American  Caesarean  operations,  103;  women 

saved,  48;  children  delivered  alive,  52. 

Laparotomy,  in  cases  of  extra-uterine  pregnancy,  appears  to  have  been 
performed  in  this  country  many  years  earlier  than  gastro-hysterotomy. 


1878.]       Harris,  The  Operation  of  Gastro-Hysterotomy.  7  9 


In  1759  Dr.  Bard,1  of  New  York,  operated  upon  Mrs.  Stagg,  about  two 
months  after  the  delivery  of  a  living  child,  and  removed  an  extra-uterine 
foetus,  which  had  been  dead  about  two  years.  Dr.  Charles  McKnight,2  of 
New  York,  performed  the  same  operation  about  1792,  on  a  woman  in  good 
health  at  the  time,  and  removed  a  foetus  which  she  had  carried  twenty- 
two  months.  Dr.  William  Bavnam,3  of  Virginia,  M.  R.  C.  S.,  London, 
operated  in  1791,  and  on  another  woman  in  179 9, 4  children  long  dead. 
All  these  four  women  recovered. 

Dr.  Philip  G.  PrioleauV  operation  in  Charleston,  S.  C,  in  1803, 
terminated  fatally  in  twenty-four  days  from  abscess  and  septic  poisoning, 
the  foetus  having  been  long  decomposed. 

Prof.  J.  Augustine  Smith,6  of  New  York,  M.  R.  C.  S.,  London,  per- 
formed the  operation  with  success  in  1808,  woman  recovering. 

Dr.  John  King,7  of  Edisto  Island,  S.  C,  operated  in  1816  by  the  post- 
uterine  vaginal  section,  and  removed  a  foetus  which  lived  ;  the  woman 
recovered. 

The  general  impression  among  medical  journalists  sixty  years  ago  ap- 
apears  to  have  been  that  ga^tro-hysterotomy  had  not  been  performed  in  the 
United  States  up  to  that  time,  at  least  not  in  the  New  England  or  Middle 
States,  and  the  most  accessible  regions  south  or  west.  This  being  the 
view  then  held,  we  are  not  likely  to  find  any  operations  prior  to  those  we 
have  already  reported. 

As  a  commenter,  who  appears  to  be  better  skilled  in  writing  than  versed 
in  medical  history,  has  fallen  into  the  error  of  supposing  that  the  term 
"  gastro-hysterotomy"  was  original  with  us,  it  may  be  well  to  state  that 
it  was  introduced  in  181G,  by  Dr.  Gardien,  one  of  the  seventy-one  con- 
tributors to  the  " Dictionnaire  des  Sciences  Medicates,"  issued  in  Paris, 
1812-22.  He  proposed  this  triple  title  for  the  Cesarean  operation  on 
purely  anatomical  grounds*,  making  a  distinction  between  it  and  the  erro- 
neously applied  French  term,  "  Hysterotomie,"  which  he  placed  at  the 
head  of  another  article,  and  confined,  as  it  should  be,  to  incisions  of  the 
uterus  through  the  vagina.  The  surgical  nomenclature  of  abdominal  opera- 
tions is  so  very  defective,  that  a  wisely  devised  distinction  such  as  this, 
should  have  been  universally  adopted.  To  appreciate  the  defects,  we 
have  only  to  examine  the  various  meanings  of  the  term  "  Gastrotomy" 
as  found  in  our  medical  periodicals. 

Correction — Through  an  error  in  the  former  article,  the  name  of 
Frederick  (Winckel)  was  made  to  take  that  of  Ludwig,  the  successful 

1  Medical  Repository,  N.  Y.,  vol.  vii.  p.  226. 

2  Memoirs  Med.  Soc.,  London,  1795,  v.  iv.  p.  342. 

3  New  York  Med.  and  Philos.  Journ.  and  Rev.,  vol.  i.  p.  163. 

4  Op.  cit.,  p.  166.  5  Med.  Repository,  vol.  vii.  p.  221. 
6  New  York  Med.  and  Philos.  Journ.  and  Rev.,  vol.  i.  p.  54. 

1  Med.  Repository,  1817,  p.  388. 


80 


Harris,  The  Operation  of  Gastro-Hysterotomy.  [July 


Cesarean  operator  of  Gummersback,  near  Cologne,  and  the  mistake  was 
not  recognized  until  too  late  for  correction. 

Case  1,  of  Tabular  Record  Dr.  E.  D.  Bassett,  in  a  letter  written  and 

published  in  1857,  says  that  the  young  quadroon  girl  recovered  from  her 
self-inflicted  incision  in  20  days,  and  that  he  saw  her  alive  and  well  at 
service  in  Troy,  six  years  afterwards. 

The  Monterey  (Mexico)  operation,  mentioned  on  page  334.  of  the  Last 
number,  was  performed  in  September,  1#77,  by  Drs.  J.  B.  Mears,  J.  H. 
Mears,  and  a  Mexican  surgeon.  The  woman  was  long  in  labour,  and  the 
difficulty  arose  from  the  existence  of  sacral  exostosis.  The  child  was 
destroyed  by  an  attempt  at  delivery  under  craniotomy,  and  had  been  dead 
twenty-four  hours  when  the  abdomen  was  opened.  The  wound  healed  by 
the  first  intention,  and  the  woman  sat  up  in  fifteen  days,  and  was  about  in 
twenty-five.  The  child,  minus  brain  and  parietal  bones,  weighed  ten 
pounds.    (Med.  and  Surg.  Reporter,  Phila.,  Oct.  27th.  1*77,  p.  32tf.) 

Case  5  has  a  remarkable  subsequent  history,  revealing  an  error  in 
pelvic  measurement  which  is  by  no  means  unique.  Dr.  Estep  was  a  good 
surgical  operator,  but  not  so  skilful  as  an  obstetrician,  in  each  of  which 
capacities  he  was  acting  in  the  first  operation.  He  gave  the  conjugate 
diameter  of  Mrs.  Stall's  pelvis  at  not  more  than  two  inches,  and  spoke 
very  positively  of  the  impossibility  of  delivering  herder  vias  naturales. 

In  1838,  four  years  after  the  second  operation.  Mrs.  S.  placed  herself 
under  the  care  of  Dr.  Robertson,  and  engaged  him  to  attend  her  in  her 
confinement.  In  due  time  he  was  summoned,  but  arriving  late,  found 
that  she  had  delivered  herself  of  "  healthy,  vigorous  twins."  This  led 
Dr.  R.  to  examine  her  pelvis  carefully,  and  lie  introduced  his  hand  fiat- 
wise  antero-posteriorly  between  the  sacrum  and  pubes,  and  computed  the 
space  at  fully  three  and  a  half  inches.  As  remarked  recently  by  an  able 
obstetrician  in  speaking  of  this  case,  "  Pelvic  measurements  on  the  living 
are  apt  to  prove  fallacious."  The  post -mortem  records  of  pelvic  deformi- 
ties will  bear  us  out  in  this. 

In  1841,  while  in  the  hands  of  a  midwife.  Mrs.  Stull's  uterus  gave  way 
along  the  line  of  the  old  cicatrix  ;  Drs.  Robertson  and  Carey  were  called 
in,  the  abdomen  opened,  and  the  child  removed,  but  the  woman  died  in 
thirty-six  hours.1  Dr.  Carey  examined  the  pelvis  and  stated  that  the 
conjugate  and  transverse  diameters  were  ••good,"  but  that  the  depth  of 
the  pelvis  posteriorly  was  less  than  usual. 

We  know  that  measuring  the  pelvis  during  labour  in  cases  of  deformity 
is  no  easy  matter  so  far  as  attaining  to  accuracy  is  concerned.  Three 
celebrated  accoucheurs  once  computed  the  conjugate  diameter  in  a  hospi- 
tal case  at  two  and  a  third  inches.  The  woman  had  been  four  days  in 
labour  under  a  midwife  before  her  admission,  and  notwithstanding  her 
pains  were  still  very  severe,  the  child  was  alive  with  a  pulse  of  145.  It 
was  decided  to  sacrifice  the  life  of  the  fetus  for  that  of  the  mother,  and 
craniotomy  was  performed.  After  the  head  was  opened  and  the  brain  re- 
moved, traction  was  made  by  seizing  the  edge  of  the  cranial  opening  with 
a  pair  of  Meigs's  craniotomy  forceps,  and  drawing  steadily  upon  them  so 

1  Reported  by  Dr.  Wm.  Bowen,  of  Massillon,  Ohio,  in  this  Journal  for  Oct.  1843, 
p.  364. 


1878.] 


Kelsey,  Pelvic  and  Abdominal  Abscess. 


81 


as  to  elongate  the  head.  In  this  way,  a  large  child,  and  just  dead,  was 
removed,  without  cutting  up  either  head  or  trunk,  in  a  moderate  time. 
We  were  present  at  the  delivery,  and  cannot  believe  it  possible  that  the 
child  could  have  been  drawn  through  the  space  given. 

Cases  7-10. — Until  quite  recently,  it  was  generally  thought  that  the  late 
Prof.  Gibson  performed  the  first  Cesarean  operation  in  the  United  States 
that  resulted  in  saving  both  mother  and  child  ;  but  we  have  in  this  paper 
shown  that  there  were  other  cases  in  advance  of  Mrs.  Raybold.  We  had 
the  pleasure  of  seeing  this  remarkable  woman  on  April  1st,  and  were  glad 
to  find  her  not  only  in  good  health,  but  looking  several  years  younger 
than  69,  which  she  recently  reached.  She  is  of  slight  frame,  very  erect, 
and  measures  4  feet  8  inches  ;  2  inches  more  than  in  the  published  reports. 
As  stated,  the  daughter  (43)  and  son  (40)  are  still  living,  and  have  four 
and  two  children  respectively.  The  superior  hygienic  advantages  enjoyed 
by  the  daughter  over  the  mother,  who  was  born  in  Ireland,  have  saved 
her  from  rickets,  and  any  consequent  parturient  difficulty.  Not  one  of 
the  eight  physicians  present  at  the  first  operation,  and  but  one  of  the  six 
at  the  second,  survives.  It  is  remarkable  that  so  small  a  woman  should 
have  survived  two  craniotomies  and  two  Cesarean  sections,  and  lived  to 
this  time.  The  coolness,  skill,  and  timely  character  of  the  operations  of 
Dr.  Gibson  had  much  to  do  witli  her  recovery  ;  and  her  accoucheurs  were 
prompt,  and  among  the  best  of  their  day  in  any  land. 
713  Locust  St.,  May  16th,  1878. 


Article  V. 

Pelvic  and  Abdomixal  Abscess.  By  Charles  Kelsey,  M.D.,  Assistant 
Demonstrator  of  Anatomy  at  the  College  of  Physicians  and  Surgeons,  New 
York. 

Since  the  publication  of  the  report  of  Dr.  Parker's  first  operation  for 
perityphlitis  in  1866,  supposed  for  some  time  to  have  been  the  first  ever 
performed,  the  surgical  treatment  of  this  and  allied  forms  of  pelvic  abscess 
by  early  incision  has  constantly  grown  in  favour,  and  the  notices  of  such 
operations  have  become  so  frequent,  that  a  single  one  is  now  scarce  worthy 
of  publication.  Among  New  York  surgeons  Sands,  Wood,  and  Buck 
have  each  reported  numerous  successful  ones,  and  the  list  has  been  in- 
creased by  individual  cases  scattered  through  current  literature,  until  the 
sum  total  is  sufficiently  large  to  place  the  desirability  of  this  method  of 
treatment  in  properly  selected  cases  beyond  the  reach  of  discussion.  For 
not  every  inflammation  around  the  right  iliac  fossa  needs  the  knife,, 
and  many  of  them  have  done  very  well  in  times  gone  by,  and  will  in  the 
future,  under  local  antiphlogistic  treatment. 

Attempts,  too,  have  been  made  from  time  to  time  to  tabulate  these 
cases,  and  draw  from  them  some  new  facts,  as  to  etiology,,  pathology,  and 
No.  CLI  July  1878.  6 


82 


Kelsey,  Pelvic  and  Abdominal  Abscess. 


[July 


differential  diagnosis,  but  with  only  partial  success  ;  for  perityphlitis  had 
been  well  studied,  and  its  pathology  well  written,  before  these  operations 
became  common,  and  but  little  that  is  essential  has  been  added  to  our 
knowledge  in  these  particulars  since  the  clinical  lessons  of  Dupuytren  and 
his  accounts  of  post-mortem  examination  -. 

Amongst  recent  writers,  none  have  approached  the  subject  in  a  more 
concise  and  scientific  way  than  Bartholow  (American  Journal  Med.  Sci- 
ences, Oct.  1866),  or  W.  T.  Bull,  in  his  prize  inaugural  thesis  of  the  class 
of  1872,  College  of  Physicians  and  Surgeons,  New  York.  Bartholow's 
classification  is  the  following  : — 

1.  Abscess  due  to  ulceration  and  perforation  of  the  caecum:  the  perfo- 
ration being  due  (a)  to  the  irritation  of  a  foreign  body ;  (b)  to  a  perforat- 
ing ulcer  which  may  be  situated  either  on  the  posterior  surface  and  uncov- 
ered by  peritoneum,  or  anteriorly  and  covered  by  peritoneum. 

2.  Abscess  due  to  ulceration  and  perforation  of  the  appendix  :  divided 
into  (a)  cases  resulting  from  simple  inflammation  and  abscess;  and  (b) 
those  from  a  foreign  body,  which  he  estimates  at  three-quarters  of  the 
whole  number  of  cases. 

3.  Abscess  due  to  inflammation  and  suppuration  of  the  sub-ca?cal  con- 
nective tissue. 

This  classification,  with  the  further  subdivisions  which  naturally  sug- 
gest themselves,  would  seem  to  cover  all  cases  of  this  disease  properly 
connected  with  the  csecum  or  its  appendix.  For  instance,  to  the  simple- 
varieties  of  ulceration  must  be  added  those  due  to  typhoid  fever  and  to 
the  softening  of  tubercular  deposits  occurring  in  the  appendix,1  as  well  as 
in  the  crecum  itself;  and  to  the  whole  museum  of  foreign  bodies  which 
have  been  found  from  time  to  time  should  be  added  the  masses  of  hard- 
ened feces  collecting  in  the  caput  coli.  and  acting  as  foreign  bodies.  Class 
3  includes  the  cases  of  violence,  the  idiopathic  inflammations,  or  those 
due  to  cold  and  strains  ;  but  we  still  have  left  the  various  collections  of 
pus  in  this  part  which  have  no  relation  to  the  intestinal  canal,  and  the 
exact  diagnosis  of  which  from  true  perityphlitis  may  at  any  time  prove  ;i 
matter  of  considerable  difficulty  ;  such  as  abscess  following  ulceration  and 
perforation  of  the  bladder,2  acute  inflammation  of  the  right  ovary  with 
purulent  pelvic  effusion;3  psoas  abscess,  cancerous  disease  of  abdominal  or 
pelvic  organs  with  purulent  degeneration,  disease  of  sacro-iliac  articula- 
tion, abscesses  after  confinement,  migration  of  pus  from  distant  parts.4  etc. 

The  difficulty  in  diagnosis  is  one  which  Habershon5  has  done  something 
to  elucidate  ;  but  from  the  nature  of  the  case  there  must  always  be  more 

1  Reynolds's  Practice,  vol.  iii.    Pathological  Transactions,  vol.  xxvii.  p.  127. 
3  Duplay.    Archives  Generales  de  Medecine,  May,  1877. 

3  Atlee.    American  Journal  of  Med.  Sciences,  July  and  October,  1877. 

4  Buck.   Abscess  in  the  Lower  Abdominal  Cavity  and  its  Parietes,  1S76. 
*  Guy's  Hosp.  Reports,  3d  series,  vol.  xxii.  1877. 


1878.] 


Kelsey,  Pelvic  and  Abdominal  Abscess. 


83 


or  less  uncertainty.  When  a  foreign  body  is  found,  the  causation  becomes 
apparent,  though  the  point  of  origin  of  the  inflammation  may  not ;  but 
when  no  such  aid  is  given,  it  may  still  be  impossible  in  any  particular 
ease  to  say  more  than  that  we  have  had  to  do  with  a  pelvic  abscess. 

In  my  own  practice  during  the  past  year,  I  have  had  three  cases  of 
deep-seated  pelvic  and  abdominal  abscess,  differing  as  far  as  possible  from 
each  other  in  their  cause,  symptoms,  and  course,  and  presenting  so  many 
points  of  contrast,  that  I  am  led  to  hope  they  may  be  of  general  interest. 

Case  I — Boy,  age  12  ;  slight,  and  of  delicate  build,  but  generally  well. 
Has  had  pain  in  abdomen  for  the  last  forty-eight  hours.  Pain  on  urina- 
tion and  defecation,  and  tenderness  all  over  lower  part  of  bowels,  but 
without  localization  in  any  one  point.  Temp.  103°,  pulse  130.  Two  soft 
evacuations  from  bowels  yesterday. 

Next  day  (third  of  -disease)  he  "  thought  it  hurt  him  more  on  the  right 
than  left  side  when  he  tried  to  stand  up,"  and  there  was  some  dulness  in 
the  right  fossa,  but  no  swelling.    Has  vomited  his  milk  once. 

4th  day.  Marked  vesical  tenesmus  and  flatulence,  occasional  vomiting; 
condition  otherwise  unchanged. 

5th  day.  Temperature  has  continued  to  range  between  101°  in  the 
morning  and  103°  in  the  afternoon.  Passed  a  very  restless  night,  and 
begins  to  show  signs  of  suffering.  There  is  flatulence,  but  not  as  much 
distension  of  the  abdomen  ;  vomiting  and  vesical  tenesmus  continue.  Has 
had  no  chill.  The  tenderness  is  now  confined  to  the  right  fossa,  and  is 
greatest  at  a  point  half  way  between  the  anterior  superior  spine  and  the 
pubes,  and  above  a  line  running  from  one  anterior  superior  spinous  pro- 
cess to  the  other,  where  a  slight  tumefaction  can  be  made  out  by  careful 
palpation.  No  superficial  redness.  Bowels  have  not  moved  since  the 
first  day.  On  consultation  with  Drs.  Sabine  and  Bullard,  it  was  decided 
that  an  operation  was  not  immediately  indicated,  and  the  same  treatment, 
quinia,  morphia,  wine,  and  fluid  diet  was  continued. 

Next  day  (sixth  of  disease)  there  was  a  marked  relief  of  all  symptoms, 
less  pain,  less  tenderness,  four  free  fluid  evacuations  from  the  bowels  in 
rapid  succession,  fall  in  temperature  and  pulse,  appetite  better,  and  has 
had  a  good  night's  sleep. 

From  the  sixth  to  the  thirteenth  day  there  was  little  change.  The 
bowels  moved  daily,  but  always  with  more  or  less  pain,  and  the  appetite 
and  strength  returned  in  a  measure  ;  so  that  he  was  able  to  leave  his  bed. 
But  the  temperature  from  day  to  day  showed  the  same  increase  above  the 
normal,  never  falling  below  100°  ;  and  the  pain  and  tenderness  did  not 
diminish.  For  a  day  or  two  the  parents  had  remarked  a  peculiar  bub- 
bling noise,  which  they  heard  at  times  at  the  seat  of  the  tumour,  and  on 
the  twelfth  day  a  part  of  the  dulness  was  found  to  have  been  replaced  by 
clear  tympanitic  resonance,  and  the  diagnosis  of  communication  between 
the  bowel  and  tumour  was  made.  On  the  thirteenth  day  he  had  a  very 
free  fluid  and  offensive  discharge  from  the  bowels  (which  the  parents  said 
contained  pus),  followed  by  a  marked  fall  in  temperature  and  diminution 
of  the  pain ;  and  for  the  next  two  days  was  comparatively  comfortable. 

IQth  day,  evening.  Complaining  of  great  pain,  rolling  and  tossing  in  bed, 
and  screaming  with  agony.  Found  him  lying  on  his  right  side,  legs  drawn 
up,  sphincter  ani  relaxed,  mucous  membrane  slightly  prolapsed,  and  a 


84 


Kelsey,  Pelvic  and  Abdominal  Abscess. 


[July 


small  stream  of  clear  mucus  flowing  from  his  anus  and  staining  the  bed  ; 
tenesmus  very  great 

Had  passed  a  small  amount  of  well-formed  feces  during  the  morning, 
and  had  been  sitting  up  enjoying  his  supposed  convalescence. 

Digital  examination  of  rectum  revealed  a  hard  tumour  pressing  upon 
and  almost  closing  it,  situated  on  the  anterior  wall,  to  the  right,  and  behind 
the  prostate.  Large  doses  of  morphia  given  to  quiet  him  through  the 
night. 

At  my  visit  next  morning  he  was  more  comfortable,  and  the  tenesmus 
had  in  part  ceased.  Had  passed  nothing  per  rectum.  On  turning  him 
on  his  back  I  was  surprised  to  see  what  appeared  to  be  a  greatly  distended 
bladder  reaching  nearly  to  the  umbilicus,  and  plainly  marked  out  on  the 
abdominal  wall.  He  had  passed  his  water  twice  during  the  night,  he  said, 
in  small  quantity,  and  was  not  suffering  from  it  at  all  then.  Stupes  over 
the  bladder  brought  away  four  ounces  of  urine  (by  measure),  and  caused 
the  entire  disappearance  of  the  visible  tumour;  the  dulness  and  hardness 
to  the  touch  still  remained  from  the  pubes  half  way  to  the  umbilicus. 
Under  ether  he  was  catheterized  and  three  or  four  ounces  more  urine  was 
withdrawn,  entirely  emptying  the  bladder.  By  careful  examination  the 
following  condition  was  then  made  out  :  A  firm,  hard  tumour  in  the  pelvis 
toward  the  right  side,  the  upper  edge  of  which  could  be  felt  by  deep  pres- 
sure about  half  way  between  the  pubis  and  umbilicus  and  the  lower  sur- 
face by  a  finger  in  the  rectum,  which  could  just  be  passed  through  the 
partly  occluded  gut  beyond  the  mass  to  its  upper  limit.  The  mass  could 
not  be  made  to  fluctuate  by  this  conjoined  manipulation,  and  the  intestine 
over  it  gave  resonance  on  percussion.  A  medium-sized  aspirator  needle 
thrust  into  the  mass  through  the  abdominal  wall  gave  us  a  pint  of  fetid, 
greenish  pus,  and  the  point  of  the  instrument  could  easily  be  felt  by  the 
finger  in  the  rectum,  nothing  but  the  wall  of  the  bowel  seeming  to  sepa- 
rate them. 

After  about  five  days  he  was  again  etherized,  and  a  free  incision  made 
into  the  tumour  from  the  rectum,  by  which  it  was  thoroughly  emptied. 
The  end  of  the  index  finger  passed  through  the  incision  into  a  large 
abscess  cavity,  the  boundaries  of  which  could  not  be  made  out.  Healing 
rapid  and  complete.  One  year  after  the  operation  the  boy  is  still  perfectly 
well. 

The  points  of  interest  in  this  case  are  the  following : — 

1st    Causation :  Nothing  like  a  foreign  body  could  be  found,  though 

thoroughly  sought  after  during  the  whole  course  of  the  discharge.  Xo 

injury. 

2d.  Position  :  The  first  symptoms — pain  on  urination  and  defecation — 
pointed  plainly  to  a  site  between  the  bladder  and  rectum,  with  a  peritonitis 
extending  from  this  point.  Afterwards  the  swelling  approached  nearer  the 
surface,  and  was  most  prominent  not  at  the  usual  place  for  a  case  of  peri- 
typhlitis, but  further  towards  the  umbilicus. 

It  was  this  position  of  the  tumour  which  kept  us  from  operating  at  the 
time  of  the  consultation,  as  I  should  have  done  had  the  matter  seemed 
nearer  the  iliac  fossa.  But,  rising  as  it  seemed  to  do  from  deeper  in  the 
pelvis,  and  gradually  coming  up  to  the  surface,  carrying  the  peritoneum 
before  it,  the  point  was  raised  by  Dr.  Sabine  whether  in  case  of  incision 


1878.] 


Kelsey,  Pelvic  and  Abdominal  Abscess. 


So 


we  might  not  empty  the  pus  into  the  peritoneal  cavity ;  and  whether  by 
waiting  a  few  days  longer  a  union  of  the  two  layers  of  peritoneum  might 
not  take  place,  and  the  danger  of  peritonitis  be  thus  diminished. 

I  have  little  doubt  in  my  own  mind  that  the  pus  was  beneath  the  pelvic 
fascia,  and  I  believe  that  in  all  cases  of  perityphlitis  the  matter  will  be 
found  outside  the  peritoneal  cavity,  not  merely  shut  off  from  it  by  adhe- 
sions with  surrounding  organs,  but  in  the  sub-peritoneal  connective  tissue. 
This  is  a  point  on  which  the  light  of  post-mortem  examinations  is  much 
needed  ;  for  though  it  is  generally  stated  that  an  abscess  arising  from  an 
ulceration  at  a  point  covered  by  peritoneum  either  bursts  directly  into  the 
peritoneal  cavity  and  causes  death,  or  is  shut  off  from  it  by  adhesions  and 
becomes  encysted,  there  are  few  of  these  later  cases  actually  recorded,  if 
any.  (?)  On  the  contrary,  where  the  exact  location  of  the  matter  is  stated, 
it  will  generally  be  found  under  the  peritoneum.  In  the  first  case  of  this 
kind  I  ever  saw,  one  in  which  the  man  died  unrelieved  by  any  attempt  at 
surgical  aid,  we  found,  post-mortem,  a  date-stone  in  the  appendix,  and  a 
collection  of  pus  which  had  worked  its  way  from  the  right  iliac  fossa 
directly  across  the  pelvis  behind  the  pubes  to  the  left,  raising  the  perito- 
neum before  it  in  its  course — a  case  which  might  in  all  probability  have 
beeD  saved  by  proper  treatment.  And  in  my  own  first  case  of  operation,1 
by  passing  our  fingers  through  the  incision  it  seemed  very  evident  that 
the  abscess  cavity  was  beneath  the  peritoneum,  though  it  is  a  delicate  point 
to  decide  under  such  circumstances.  But  I  observe  the  same  ground  has 
recently  been  taken  by  Dr.  Sands,2  and  I  remember  hearing  the  late  Dr. 
Krakowiczer  express  himself  very  strongly  in  the  same  way  in  the  discus- 
sion of  a  paper  by  Dr.  Gurdon  Buck,3  also  deceased,  who  held  to  the  con- 
trary. However,  we  have  better  testimony  than  opinion  on  this  point. 
Duplav,  in  his  Archives  Generates  de  Medecine,  May,  1877,  in  describing 
the  post-mortem  of  a  man  who  died  of  pelvic  abscess  subsequent  to  ulcer- 
ation and  perforation  of  the  bladder,  says  : — 

"  By  these  two  incisions  a  large  cavity  was  opened,  occupying  all  the  hypo- 
gastric region,  containing  putrid  gas  and  a  small  quantity  of  dark,  brownish  fluid. 
This  cavity,  with  irregular  walls,  was  limited  in  front  by  the  abdominal  muscles 
partly  destroyed  and  reduced  to  a  black  gangrenous  mass  ;  behind  and  above  by 
a  thick  membrane  of  brown  colour,  gray  in  spots,  covered  by  thick  and  adherent 
pus,  presenting  an  uneven  softened  surface.  This  membrane,  which  completely 
separated  the  purulent  collection  from  the  intestines  and  the  absolutely  healthy 
peritoneal  cavity,  appeared  to  be  constituted  by  the  peritoneum  itself  separated 
from  the  abdominal  muscles." 

And  Dupuytren,4  describing  the  post-mortem  of  a  case  of  true  peri- 
typhlitis from  perforation  of  the  appendix,  says  : — 

"The  skin  was  perforated  by  four  openings  which  communicated  with  each 
other,  and  opened  together  into  a  large  cavity  or  pouch  situated  between  the  mus- 


1  N.  T.  Medical  Record,  vol.  ix.  p.  511.         2  K.  T.  Med.  Record,  Jan.  19,  1878. 

3  Transactions  of  N.  T.  Acad,  of  Med.,  series  2d,  vol.  ii.  1876. 

4  LejDns  Orales,  vol.  iii.  page  522.    Ed.  of  1839. 


86 


K  e  l  s  e  y  ,  Pelvic  and  Abdominal  Abscess. 


[July 


cles  of  the  abdominal  icall  and  the  external  surface  of  the  peritoneum."  Also 
on  the  next  page,  in  a  similar  case  :  "  The  opening  of  the  cadaver  showed  a  large 
pouch  having  its  seat  in  the  cellular  tissue  surrounding  the  caecum,  with  its  bur- 
rowings  following  the  direction  of  the  psoas  and  iliacus  muscles." 

There  are  many  such  descriptions,  but  I  do  not  remember  meeting 
any  where  the  pus  was  described  as  encysted  in  the  cavity  of  the  peri- 
toneum. It  seems  astonishing,  in  fact,  what  an  amount  of  pressure  and 
tearing-up  from  its  place  the  peritoneum  will  bear  from  a  collection  of  pus 
beneath  it  without  becoming  perforated. 

Another  point  of  great  interest  in  this  case  was  the  prominence  given  to 
the  bladder  by  so  small  an  amount  of  urine  (8  oz.),  causing  it  to  rise  over 
the  tumour  nearly  up  to  the  umbilicus  ;  and  the  diagnostic  value  of  the 
continued  rise  in  temperature,  when  in  every  other  respect  the  patient 
seemed  on  the  point  of  recovery,  should  not  be  lost  sight  of. 

Case  II — Susan  M.,  aged  4o,  widow.  Three  years  ago  patient  was 
operated  upon  for  ovarian  tumour.  The  site  of  the  incision  is  occupied  by 
a  hernia  the  size  of  a  closed  fist. 

For  two  or  three  years  past  she  has  had  more  or  less  pain  in  the  region 
of  the  stomach  and  liver,  and  has  several  times  been  jaundiced.  She  de- 
scribes several  attacks  which  might  be  attributed  to  the  passage  of  a  gall- 
stone, and  has  been  treated  under  this  diagnosis  ;  but  for  some  time  past 
the  pain  has  been  almost  constant ;  there  has  been  occasional  vomiting 
and  constipation,  but  no  jaundice  or  sudden  exacerbations  in  the  pain. 

At  the  time  of  my  seeing  her  she  was  suffering  greatly,  but  could  not 
point  out  the  exact  seat  of  the  pain,  which  seemed  to  be  general  over  the 
abdomen.  She  was  in  good  flesh  ;  bowels  confined  ;  urine  normal ;  appe- 
tite poor ;  vomiting  occasional ;  some  fever,  and  occasional  slight  chills. 
Physical  examination  revealed  nothing.  She  was  put  upon  alkaline  treat- 
ment under  the  probable  diagnosis  of  impacted  gall-stone. 

During  the  next  three  weeks  I  saw  her  daily.  The  pain  sometimes 
ceased  for  a  day  or  two,  and  then  was  as  bad  as  before  for  a  longer  or 
shorter  period.  There  was  never  any  jaundice,  and  careful  examination 
of  the  abdomen  failed  to  reveal  anything  abnormal ;  the  liver  seemed  to 
be  about  the  right  size,  and  was  not  tender  on  pressure  ;  but  the  fever  and 
occasional  chilly  feelings  remained,  and  she  gradually  lost  strength  and 
flesh.  At  the  end  of  that  time  she  was  received  into  St.  Luke's  Hospital, 
and  for  the  remainder  of  the  history  I  am  indebted  to  Dr.  Beauvelt,  the 
present  house  physician. 

For  the  next  month  there  was  little  change  in  the  condition  ;  but  at 
the  end  of  that  time  a  tumour  was  discovered  in  the  right  side  of  the  ab- 
domen below  the  liver,  large,  deeply  seated,  and  tender  to  pressure  ;  and 
she  seemed  to  be  sinking  under  the  prolonged  fever  and  suffering.  After 
another  month  the  tumour  had  burst  at  the  site  of  the  old  cicatrix  in  the 
median  line,  and  was  discharging  a  large  quantity  of  pus  daily.  A  probe 
introduced  at  this  point  passed  a  long  distance  upward  in  the  sheath  of  the 
rectus  muscle.  For  a  while  it  seemed  as  though  the  patient  might  rally, 
but  she  gradually  ran  down  again,  and  Anally  died,  worn  out  by  the  suppu- 
ration, about  five  months  from  the  time  I  first  saw  her. 

Autopsy. — Liver  not  much  changed  in  size ;  gall-bladder  stuffed  full  of 
a  mass  of  calculi,  which  came  out  as  one  piece,  but  were  separated  into 
twenty-five  different  stones  by  washing.    This  mass  had  caused  ulceration 


1878.] 


Kelsey,  Pelvic  and  Abdominal  Abscess. 


87 


and  perforation  of  the  gall-bladder,  which  communicated  with  a  large  ab- 
scess cavity  under  the  liver  and  close  to  the  diaphragm  ;  and  the  pus  from 
this  abscess  had  burrowed  upward  along  the  diaphragm  to  the  substance 
of  the  rectus  muscle,  and  along  this  to  the  point  of  opening  in  the  cicatrix 
of  the  old  ovariotomy,  about  half  way  between  the  symphysis  pubis  and 
the  umbilicus. 

The  next  case  is  interesting,  not  so  much  on  account  of  any  difficulty 
in  diagnosis  as  of  the  treatment,  which  was  very  successful,  and  which  I 
should  be  much  inclined  to  repeat  should  a  similar  occasion  arise.  I  can 
easily  see,  however,  how  such  a  case  occurring  on  the  right  side  instead 
of  the  left,  might  be  very  difficult  to  diagnosticate  from  an  abscess  con- 
nected with  the  caecum,. or  appendix,  especially  in  such  a  case  as  the  one 
reported  by  Kiwisch  when  the  cyst  contained  fifteen  pints  of  pus.1 

C  ase  III. — Mile.  L.,  age  2C>.  Has  been  a  constant  sufferer  from  dys- 
menorrhea. Unwell  one  week  before  my  first  visit,  and  while  so,  took 
a  bath  in  the  surf.  Found  her  suffering  great  pain  in  the  region  of  the 
left  ovary,  with  some  fever.  Ordered  rest  in  bed,  with  the  usual  applica- 
tions, and  in  the  course  of  four  days  she  was  able  to  come  to  my  office, 
and  a  vaginal  examination  was  made,  revealing  retroversion,  chronic 
endometritis,  and  parametritis,  with  tenderness  on  pressure  and  manipu- 
lation both  of  the  uterus  and  left  ovary. 

Next  day  there  Avas  a  return  of  all  the  acute  symptoms,  caused  possibly 
by  the  examination  or  by  over-exertion  on  her  part,  and  for  about  three 
weeks  she  was  confined  to  her  bed  with  constant  fever,  pain  on  urination 
and  defecation,  inability  to  extend  the  left  thigh,  which  she  kept  constantly 
flexed  on  the  abdomen,  and  great  tenderness  over  the  left  ovary. 

At  the  end  of  this  time  a  thorough  examination  was  made  under  ether, 
and  a  large  mass  of  inflammatory  exudation  around  the  ovary  easily  made 
out  by  the  finger  in  vagina  or  rectum.  Into  this  mass  an  aspiration  nee- 
dle was  plunged  through  the  abdominal  wall  with  one  finger  in  the  vagina 
to  steady  the  tumour.  The  needle  entered  with  considerable  difficulty, 
owing  to  the  hardness  of  the  tissue,  but  at  length  passed  into  an  evident 
cavity,  and  from  this  about  half  an  ounce  of  good  pus  without  offensive 
odour  was  withdrawn.  The  needle  was  then  forced  onward  into  the  vagina 
with  the  idea  of  using  it  as  a  director  upon  which  to  make  a  counter 
opening  at  this  point;  but  this  was  found  to  be  so  difficult  to  accomplish 
satisfactorily  that  it  was  finally  withdrawn,  and  the  opening  into  the 
vagina  postponed  for  a  future  operation  if  necessary. 

The  relief  to  all  symptoms  was  very  marked.  The  abscess  cavity  never 
again  filled,  and  after  a  couple  of  months'  treatment  by  rest  and  hot  injec- 
tions, a  retroversion  pessary  was  introduced,  and  the  patient  was  able  to 
resume  her  ordinary  occupations  without  discomfort. 

48  East  30th  Steeet,  New  York. 


1  Tanner.    Signs  and  Diseases  of  Pregnancy,  p.  164. 


88 


Duhring,  Atrophy  of  the  Hair  of  the  Beard. 


[July 


Article  VI. 

Case  of  an  Undescribed  Form  of  Atrophy  of  the  Hair  of  the 
Beard.1  By  Louis  A.  Duhring,  M.D.,  Professor  of  Skin  Diseases  in  the 
University  of  Pennsylvania,  Dermatologist  to  the  Philadelphia  Hospital,  etc. 

The  case  that  I  am  about  to  describe  represents  an  interesting  and,  I 
think,  new  form  of  disease  of  the  hair.  It  consists  of  a  chronic  disease 
of  the  hair  of  the  beard,  characterized  by  atrophy  of  the  hair-bulb,  and  by 
splitting  of  the  hair-substance,  producing  irritation  of  the  follicles,  and 
giving  rise  to  disfigurement. 

The  subject  is  a  physician,  thirty-three  years  of  age,  of  average  height 
and  proportions,  with  dark  complexion  and  blackish  hair.  I  first  saw 
him  one  year  ago.  He  stated  that  he  was  suffering  with  a  singular  dis- 
ease of  the  beard,  which  gave  him  great  mental  worriment  and  considera- 
ble discomfort.  He  had  had  it  for  some  years,  and  although  it  had  been 
vigourously  treated,  no  benefit  had  resulted.  He  added  that  neither  he 
nor  the  several  physicians  whom  he  had  consulted  had  been  able  to  arrive 
at  a  conclusion  regarding  the  nature  of  the  disease,  but  that  by  some  it 
had  been  considered  to  be  parasitic. 

I  found  him  of  a  highly  nervous  temperament,  and  exceedingly  dis- 
turbed in  mind  about  his  condition.  His  general  health  was  below  the 
average.  He  was  dyspeptic,  and  suffered  with  an  irritable  prostate  gland. 
The  hair  of  the  scalp  was  cut  quite  close,  and  presented  no  peculiarities. 
Upon  the  upper  lip  he  carried  a  long,  narrow,  brownish  moustache,  which, 
except  that  it  was  noticeably  narrow,  and  had  an  irregular,  broken  upper 
border,  appeared  to  be  healthy.  The  rest  of  the  face  possessed  about  a 
week's  growth  of  dark-brown,  manifestly  more  or  less  diseased  hair,  which 
was  nowhere  abundant,  and  moreover  inclined  to  grow  in  patches.  The 
hair  upon  other  regions  of  the  body  was  normal.  He  gave  the  following 
account  of  the  affection  :  It  first  manifested  itself  about  seven  years  ago, 
upon  either  side  of  the  chin,  in  the  form  of  small  irregular  areas  about  the 
size  of  a  dime.  He  was  not  at  that  time  in  the  habit  of  shaving,  but  wore 
a  full  beard,  which  was  thick,  luxuriant,  and  perfect  as  regards  the  hair. 
He  noticed  that  the  hairs  of  the  patches  referred  to  became  dry,  brittle, 
and  split  up,  and  that  they  broke  off  here  and  there,  leaving  ragged  ex- 
tremities. Shaving  of  the  whole  face  was  hoav  instituted,  and  kept  up  for 
a  period,  but  it  was  noted  that  the  disease  still  continued,  and  that  it  was 
very  gradually  encroaching  on  new  territory.  Three  years  ago  it  made 
its  appearance  around  the  upper  border  of  the  moustache  on  either  side, 
where  it  has  persisted,  creeping  downwards  very  slowly  to  its  present  line. 

He  states  that  he  has  observed  that  the  effect  of  shaving  is,  upon  the 
whole,  beneficial.  If  daily  shaving  be  practised,  the  skin  and  the  hairs  in 
time  assume  a  healthier  appearance.  As  soon,  however,  as  the  hairs  are 
permitted  to  grow,  the  abnormal  condition  reappears.  More  or  less  irri- 
tation of  the  skin  and  slight  scaliness  of  the  affected  regions  are  at  all  times 
present,  but  in  a  marked  degree  only  after  the  beard  has  existed  for  some 
days.    Occasionally  the  disturbance  of  the  follicles  is  so  great  that  small  fol- 

1  Eead  before  the  American  Dermatol  ogical  Association,  at  its  first  annual  meeting, 
at  Niagara  Falls,  Sept.  1877. 


1878.] 


D  u  H  ring,  Atrophy  ot  the  Hair  of  the  Beard. 


89 


licular  papules  and  pustules  form  here  and  there.  If  the  beard  be  allowed 
to  grow  for  a  fortnight,  the  hairs  assume  a  stiff,  brittle,  split-up  condition, 
the  free  ends  showing  brush-like  extremities,  while  the  skin  becomes 
hyperaemic  or  inflamed  and  scaly.  Sooner  or  later  the  hairs  loosen,  and 
may  be  easily  pulled  out,  or  in  time  drop  out.  Repeatedly  of  late  the 
patient  lias  resolved  to  permit  the  beard  to  grow  indefinitely,  for  the  pur- 
pose of  further  studying  the  course  of  the  disease  ;  but  at  the  end  of  a 
fortnight  the  irritation  and  disfigurement  have  been  so  great  that  he  has 

©  ©  © 

been  compelled  to  abandon  his  determination.  The  disease,  he  states,  is 
in  a  much  more  active  condition  now  than  it  was  a  year  or  two  since. 

The  subjective  symptoms  he  describes  as  being  very  annoying,  consist- 
ing of  more  or  less  itching  and  general  irritation  of  the  affected  parts. 
They  are  decidedly  worse  when  the  beard  is  growing. 

The  present  appearance  of  the  disease  may  be  described  as  follows  :  It 
will  be  remembered,  as  stated,  that  a  week's  growth  of  hair  exists  upon 
the  chin,  and  that  the  moustache  is  of  full  length.  The  regions  invaded 
are  two  indistinctly  defined,  irregularly  ovalish  areas,  about  as  large  as 
olives,  on  either  side  of  the  chin  between  the  median  line  and  the  angle  of 
the  lower  jaw.  They  come  down  over  the  chin  quite  symmetrically,  almost 
joining  at  the  median  line.  The  upper  lip  is  attacked  in  the  form  of  two 
irregularly  shaped,  elongate  patches,  extending  on  either  side  from  the 
lower  border  of  the  nares  to  the  angles  of  the  mouth ;  in  other  words, 
completely  around  the  upper  border  of  the  moustache,  which  is  in  part 
destroyed.  The  remainder  of  the  moustache  is  normal.  The  side  whis- 
kers  as  well  as  the  hair  of  the  neck  are  likewise  unaffected.  Around  the 
outer  border  of  the  moustache  the  hairs  are  entirely  wanting,  the  diseased 
areas  having  been  recently  depilated.  The  skin  is  slightly  reddened  and 
scaly,  and  has  the  appearance  of  being  the  seat  of  seborrhoea.  As  already 
stated,  the  moustache  is  unusually  narrow  and  presents  a  broken,  irregular 
upper  outline.  The  patches  upon  the  sides  of  the  chin  have  a  hyperaemic, 
scaly  surface,  and  are  partially  bald,  the  hairs  that  remain  being  plainly 
diseased.  Here  and  there  are  minute  follicular  papules  and  pustules. 
The  free  extremities  of  the  hairs  are  split  up  into  two  or  more  parts,  giv- 
ing the  hairs  a  ragged  look.  They  are  of  irregular  length  and  calibre ; 
some  are  uncommonly  thick,  while  others  are  remarkably  thin  and  atro- 
phied. One  hair  only  is  noted  to  proceed  from  a  follicle.  There  is  no 
swelling  of  the  skin,  but  the  surface  is  hyperaemic  and  slightly  scaly,  and, 
as  upon  the  upper  lip,  resembles  seborrhoea.  The  condition  also  bears 
some  likeness  to  tinea  circinata  of  this  region,  but  not  to  tinea  sycosis,  for, 
as  stated,  there  is  no  swelling  of  the  tissues. 

The  hairs  when  seized  with  the  forceps  are  found  in  some  instances  to 
be  firmly  seated  in  their  follicles,  and  in  other  cases  to  be  so  loose  that  they 
may  be  readily  extracted.  Depilation  is  in  no  instance  painful.  Even 
the  hairs  which  are  securely  lodged  may  be  pulled  out  without  causing  th  e 
least  pain.  This  has  always  been  the  case,  and  has  been  noted  by  the 
patient  as  being  a  singular  feature  of  the  disease.  With  some  hairs  depila- 
tion is  difficult,  the  hairs  breaking  off  leaving  the  roots  within  the  follicles. 

To  the  naked  eye  the  extracted  hairs  are  seen  to  vary  greatly  in  appear- 
ance. They  are  from  one  to  several  lines  in  length.  Some  have  a  uniform 
diameter,  several  times  greater  than  normal,  while  others  throughout  their 
length  are  unusually  slender.  They  also  vary  in  form,  some  being  straight, 
others  crooked.  The  bulbs  are  in  almost  all  instances  smaller  than  nor- 
mal, and  have  a  markedly  contracted  look.    Not  unfrequently  the  diameter 


90 


Duiiring,  Atrophy  of  the  Hair  of  the  Beard. 


[July 


of  the  bulb  and  root  is  considerably  less  than  that  of  the  shaft.  The  shaft- 
are  either  diminutive,  in  which  case  they  are  generally  free  of  root-sheath  ; 
or,  they  are  of  large  calibre  and  surrounded  with  adherent  root-sheath. 

The  majority  of  the  hairs  show  splitting  into  two,  three,  or  more  parts 
throughout  their  entire  length.  The  extent  of  the  splitting  varies ;  in 
some  hairs  the  substance  is  split  up  into  a  number  of  parts,  or  stalks,  widely 
separated,  while  in  other  specimens  the  stalks  hold  together,  so  that  the 
form  of  the  hair  is  still  preserved,  although  larger  than  normal.  Many  of 
the  hairs  look  as  though  they  might  have  been  cleft  with  a  delicate  knife. 
In  other  cases  the  disintegration  is  in  a  less  advanced  stage,  the  hairs 
showing  merely  indications  of  splitting. 


Specimens  of  hair  showing  the  several  varieties  of  disease.    20  diameters. 

Under  the  microscope  the  hairs  exhibit  still  greater  diversity  of  struc- 
ture, as  may  be  seen  in  the  accompanying  drawing.  They  are,  in  the  first 
place,  notable  for  their  irregularity  of  form,  scarcely  two  of  them  being 
alike.  Atrophy  of  the  bulbs  and  fission  of  the  hair  substance  are  the  con- 
spicuous features.  In  the  majority  of  the  specimens  the  bulbs  are  distinctly 
shrunken  and  atrophied,  appearing  as  small  contracted  points  or  knobs. 
The  hairs,  as  a  rule,  begin  to  fissure  within  the  bulb,  the  separation  of  the 
parts  taking  place  either  at  the  bulb  or  at  a  variable  distance  beyond  it. 
The  hair  structure  is  noted  to  divide  very  irregularly  into  two,  three,  four 
or  more  parts,  which  either  adhere  throughout  the  length  of  the  hair,  or 
diverge  at  once,  and,  in  some  cases,  split  again  into  other  stalks.  The 
splitting  and  branching  may,  I  think,  be  quite  appropriately  compared  to 
this  process  as  it  takes  place  in  many  elm  trees,  where  the  limbs  are  often 


1878.] 


Duh  ring,  Atrophy  of  the  Hair  of  the  Beard. 


91 


thrown  off  at  no  great  distance  from  the  roots.  No  uniformity  is  observed 
in  the  fission  ;  some  stalks  spring  directly  from  the  bulb,  others  are  formed  by 
the  division  of  a  stalk.  They  vary  as  to  number  and  size.  The  majority 
of  hairs  show  from  three  to  five  stalks.  Some  are  short  and  thick ;  others 
are  long  and  slender.  As  a  rule,  they  incline  to  diverge  widely  as 
the  free  extremity  is  approached,  giving  the  hair  somewhat  the  form 
and  appearance  of  a  feather  brush.  They  either  retain  their  original 
calibre  throughout  their  length,  or  they  gradually  enlarge  towards  their 
free  ends,  in  some  instances  to  fully  double  the  size  they  possess  at 
their  point  of  departure  from  the  main  structure.  This  is  a  striking  and, 
at  the  same  time,  a  curious  feature  of  the  disease,  and  is  well  shown  in  one 
of  the  drawings. 

The  cortical  substance  has  either  a  dry,  brittle  look,  as  occurs  in  the 
atrophied,  slender  stalks,  or  it  possesses  a  spongy,  luxuriant  appearance,  as 
is  seen  in  the  thick,  hypertrophied  parts.  The  medulla,  is  nowhere  normal. 
It  is  present  here  and  there,  but  in  broken  tracts.  In  many  specimens 
nothing  further  than  an  irregular  streak  of  pigment  can  be  found,  either 
at  the  bulb  or  in  the  shaft.  The  distribution  of  pigment,  is  variable  as  to 
quantity  and  localization.  In  some  hairs  it  is  concentrated,  as  about  the 
bulbs;  in  others  it  is  noticeably  wanting.  The  hairs  vary  in  colour  from 
yellowish  to  blackish. 

The  exterior  surface  of  the  hairs  varies;  in  some  cases  it  is  smooth,  in 
others  dry,  rough,  broken,  and  ragged.  Here  and  there  are  noticed  jagged 
processes  and  spicules  of  partially  detached  filaments. 

Concerning  the  treatment  to  which  the  disease  has  been  subjected,  it 
may  be  stated  that  various  methods  have  been  instituted  and  carried  out 
more  or  less  faithfully,  including  both  internal  and  local  remedies.  Among 
the  former,  arsenic,  strychnia,  iron,  iodide  of  potassium,  and  Donovan's 
solution  may  be  mentioned,  none  of  which  exerted  any  influence  on  the 
affection.  Locally,  close  shaving  and  depilation  have  been  practised  on 
several  occasions,  but  never  for  a  long  period.  During  the  time  when  the 
disease  was  regarded  as  being  probably  due  to  a  vegetable  parasite,  para- 
siticides were  freely  employed,  without  benefit.  The  only  remedies  likely 
to  prove  of  value,  in  my  opinion,  are  long-continued  shaving  and  depila- 
tion. 

The  disease  is  one  of  interest  on  account  of  its  rarity  and  for  the  pecu- 
liar pathological  changes.  The  symptoms,  moreover,  combine  to  render 
it  both  an  annoying  and  a  disfiguring  affection.  Regarding  its  pathology 
we  learn  from  microscopic  study  that  the  morbid  process  takes  its  origin 
at  the  base  of  the  bulb,  and  consequently  manifests  itself  as  soon  as  the 
hair  commences  to  grow.  The  changes  take  place  within  the  follicle. 
With  the  development  of  the  hair  occurs  atrophy  of  the  bulbs,  followed  by 
fission,  and  subsequently  irregular  growth  of  the  hair-substance.  The 
increase  in  the  bulk  of  the  hair,  caused  by  the  separation  of  its  parts,  ren- 
ders it  too  large  for  the  follicle,  which  becomes  distended  and  more  or  less 
inflamed.  The  clinical  symptoms  are  by  this  explanation  satisfactorily 
accounted  for.  The  most  striking  feature  of  the  disease  is  found  in  the 
fact  that  while  the  bulbs  are  in  a  state  of  marked  atrophy,  the  root  and 
shaft  show  apparent  hypertrophy,  and  in  some  cases  this  in  a  remarkable 
degree.    The  phenomenon  admits  of  no  explanation. 


02 


Muhlenberg,  Gunshot  Wound  of  the  Face. 


[July 


The  theory  of  the  parasitic  nature  of  the  affection  need  be  mentioned 
merely  to  be  disposed  of  as  being  entirely  out  of  the  question.  No  sign  of  any 
vegetable  organism  was  found  within  the  hair  or  in  any  of  the  epithelial 
cells  of  the  epidermis  or  follicle.  The  microscopic  examinations  were 
conducted  with  much  care,  a  large  number  of  hairs,  together  with  epithe- 
lial matter  taken  from  the  follicles  and  epidermis,  having  been  viewed 
under  both  low  and  high  powers.  The  specimens  were  obtained  and  ex- 
amined on  several  occasions,  and  at  intervals  of  months,  with  invariably 
the  same  result. 

Splitting  of  the  hair  taking  place  without  the  follicle  is  by  no  means  a 
rare  condition,  and  may  exist  in  all  degrees  of  severity.  It  occurs  in  the 
long  fine  hairs  of  the  scalp,  and  also  less  frequently  in  the  shorter  hairs  of 
the  beard.  A  case  of  simple  splitting  of  the  hair  of  the  beard  occurring 
in  a  gentleman  of  thirty  witli  reddish  hair,  is  at  the  present  time  under 
my  observation.  The  hairs,  upon  being  allowed  to  grow  to  any  length, 
become  dry  and  brittle,  and  split  up  at  their  free  extremities  into  two  or 
more  parts,  giving  the  beard  a  somewhat  curly,  bushy  appearance. 

In  conclusion,  it  may  be  remarked  that  the  disease  which  is  the  subject 
of  this  communication  must  be  regarded  as  one  of  atrophy  of  the  hair,  and 
may  be  grouped  with  that  singular  and  rare  disease  which  was  first  de- 
scribed by  Beigel  under  the  name  of  "  swelling  and  bursting  of  the  hairs" 
(Sitzb.  d.  k.  Akad.  d.  W.  bd.  xvii.  p.  612,  18.5.3).  Kaposi,  who  has  also  met 
with  the  disease  of  Beigel,  just  referred  to,  proposes  for  it  the  name  "  tricho- 
rexis  nodosa"  (Hebra  and  Kaposi,  Diseases  of  the  Skhi,  New  Syd.  Soc. 
Trans.,  vol.  iii.  p.  244).  The  affection  described  by  Devergie,  and  called  by 
him  "  tricoptilosis"  (Annales  de  Derm,  et  de  Syph.  No.  i.  1871,  1872),  is 
doubtless  the  same  disease  as  the  "  swelling  and  bursting  of  the  hairs"  of 
Beigel.  It  differs  in  many  particulars  from  the  disease  under  considera- 
tion. 


Article  YII. 

A  Guxshot  YVouxd  of  the  Face,  together  with  the  Descriptiox  of 
a  Splixt  adapted  for  Compouxd  Fractures  of  the  Upper  Jaw. 
By  W.  F.  Muhlenberg,  M.D.,  of  Reading,  Pa. 

During  the  railroad  riot  that  took  place  in  Beading  on  July  23,  1877, 
E.  H.,  aged  23,  was  shot  through  both  cheeks,  whilst  slightly  under  the 
influence  of  liquor. 

The  hemorrhage,  qaite  profuse  at  first,  soon  stopped  after  the  patient  had 
passed  into  a  state  of  partial  syncope.  No  large  arteries  were  apparently 
injured,  and  by  the  next  day  the  venous  oozing  had  entirely  ceased. 
The  ball,  probably  a  large  sized  minie.  entered  the  right  cheek  at  the 
intersection  of  a  line,  extending  three  inches  horizontally  from  the  ear. 
with  another  2  J  inches  long,  drawn  perpendicular  to  the  outer  edge  of  the 


1878.]        Muhlenberg,  Gunshot  Wound  of  the  Face. 


93 


superciliary  ridge.  Its  course,  after  passing  through  the  anterior  portion 
of  the  right  malar  bone,  was  directly  through  the  face,  and  then  out  on 
the  opposite  side,  at  an  almost  identical  position. 

The  damage  to  the  bones  of  the  face  was  excessive,  and  the  face,  to  use 
the  language  of  one  of  the  physicians  who  saw  it,  "  was  nothing  but  a  bag 
of  bones/'  Every  bone,  except  the  inferior  maxilla,  was  fractured,  either 
in  a  simple  or  comminuted  manner.  The  ethmoid,  and  probably  the 
sphenoid,  were  also  broken.  Both  superior  maxilla?,  detached  completely 
from  any  bony  union,  protruded  at  least  an  inch  in  front  of  their  normal 
position,  and  fell,  over  an  inch,  almost  to  the  level  of  the  chin,  while 
the  upper  teeth  protruded  and  projected  far  beyond  and  below  the  lower. 
The  fracture,  directly  across  the  face,  separated  the  orbital  portions  of  both 
superior  maxilla?  from  the  bodies  of  the  bones.  A  fracture  in  the  roof 
of  the  mouth  followed  very  closely  the  line  of  union,  between  the  superior 
maxillary  and  palate  bones,  extending  immediately  in  front  of  the  second 
upper  molar  of  the  right  side,  through  the  roof  of  the  mouth  and  floor  of 
the  nasal  cavity,  to  a  point  before  the  last  upper  molar  of  the  left  side. 

There  was  also  an  antero-posterior  fracture  in  the  roof  of  the  mouth, 
completely  separating  both  superior  maxilla?.  In  addition,  in  the  roof  of 
the  mouth  there  were  a  number  of  incomplete  fractures  and  fissures. 

The  gap  in  the  cheeks  between  the  dislodged  and  orbital  portions  of  both 
superior  maxilla?  was  fully  an  inch  wide,  and  disclosed,  on  palpation  and 
probing,  numerous  fragments  and  spicula  of  bone.  The  space  in  the 
mouth  between  the  palate  and  superior  maxillary  bones  was  large  enough 
to  admit  the  little  finger.  Both  nasal  bones  were  comminuted.  The 
vomer  was  fractured,  and  quite  a  large  portion  was  driven,  by  the  force 
of  the  ball,  through  the  cheek,  and  extracted,  on  the  following  day,  at 
about  the  normal  position  of  the  left  malar  bone.  The  turbinated  bones 
were  also  broken  extensively. 

Besides,  the  orbital  portion  of  the  superior  maxilla  of  the  left  side  was 
dislodged,  and  on  the  following  day,  after  the  removal  of  some  impacted 
fragments  of  bones  in  the  cheek,  the  entire  anterior  portion  of  the  floor  of 
the  left  orbit,  together  with  the  eye,  sank  down  half  an  inch,  although  sub- 
sequently the  level  of  the  eye  was  raised  to  almost  its  normal  position  by 
the  great  effusion  that  resulted.  The  ethmoid  bone  was  fractured,  as  was 
shown  by  the  inspection  of  fragments  subsequently  removed.  The  lach- 
rymal bone  of  the  left  side  was  dislodged,  and  forced  down  into  the  nasal 
cavity.  The  right  malar  bone  was  only  slightly  injured,  while  very  little 
remained  of  the  left  malar  bone,  except  its  orbital  portion.  The  inferior 
maxilla  was  not  at  all  injured. 

The  face  of  the  patient,  subsequent  to  the  injury,  was  more  canine  than 
human,  as  evidenced  by  the  sinking  in  of  the  bridge  of  the  nose,  the  pro- 
trusion and  dependency  of  the  upper  lip  and  adjacent  portion  of  the  cheek, 
and  the  relative  retraction  of  the  chin  and  lower  portion  of  the  face. 

The  wound  of  entrance  was  about  the  size  of  the  ball  that  produced  it, 
while  the  wound  of  exit  extended  from  the  base  of  the  left  nostril  and 
inner  canthus  of  the  left  eye,  in  a  Y  shape,  near  to  the  left  temple. 

The  different  bones  and  fragments  of  bones  lodged  between  the  upper 
and  lower  portions  of  the  superior  maxilla?  were  firmly  impacted,  and  re- 
quired considerable  force  and  time  to  remove  them.  Although,  after  their 
removal,  the  lower  portion  of  the  upper  jaw  hung  apparently  by  only  a 
very  slight  muscular  adhesion,  and  allowed  all  necessary  examinations, 
still  after  effusion  took  place,  any  examination  of  the  mouth  became  dim- 
cult,  and  finally  almost  impossible. 


04 


Muhlenberg,  Gunshot  Wound  of  the  Face.  [July 


The  great  difficulty  which  presented  itself  was,  how  to  feed  the  patient. 
It  was  impossible  for  him  to  masticate  any  food,  or  even  to  draw  liquid 
nourishment  through  a  tube,  not  only  because  the  mouth  and  nose  were 
almost  as  one  cavity,  communicating  freely  with  each  other  and  the  out- 
side air,  but  also  because  any  muscular  action  of  the  cheeks  necessary  for 
such  an  operation  was  prevented  by  their  loss  of  power,  and  by  the  utter 
inability  to  keep  the  lips  closed.  He  was  fed  by  inserting  a  small  gum 
tube  into  a  tumblerful  of  liquid  food,  raised  above  the  level  of  his  mouth, 
starting  a  siphonic  flow,  and  then  insinuating  the  end  of  the  tube  between 
the  two  jaws,  and  allowing  the  fluid  to  trickle  down  his  throat.  This 
was  comparatively  easy  for  a  short  time,  as  the  upper  jaw  could  readily 
be  raised  a  very  short  distance,  so  as  to  allow  the  tube  to  be  inserted, 
but  after  the  swelling  and  effusion  had  taken  place  was  very  difficult, 
as  the  tube  had  to  be  pushed  upwards  and  then  backwards  before  it  could 
enter  the  cavity  of  the  mouth,  owing  to  the  advanced  and  dependent 
position  of  the  upper  jaw,  and  its  almost  total  immobility.  However, 
this  method  of  feeding  was  continued  for  six  weeks,  until,  by  the  use  of 
the  splint,  the  upper  jaw  could  again  be  raised.  The  patient  suffered 
considerable  pain  from  the  passage  of  liquids,  like  brandy,  beef  tea,  etc., 
over  the  raw  surfaces  of  the  mouth  ;  but  notwithstanding  the  discomfort, 
submitted  patiently  to  all  these  annoyances. 

The  treatment  used  was  the  general  one.  The  external  wounds  were 
covered  with  linen  cloths,  which  were  removed  every  fifteen  minutes, 
night  and  day.  These  rags  were  dipped  in  ice-water,  holding  in  solution, 
carbolic  acid,  laudanum,  and  lead-water.  This  mode  of  external  treatment 
was  continued  for  four  days,  when  hot  flaxseed  poultices,  renewed  every 
half  hour,  were  substituted  for  it,  owing  to  the  flabby  and  lifeless  appear- 
ance of  the  wound.  On  consultation  with  a  number  of  physicians  of 
Reading,  it  was  considered  impossible  to  save  the  upper  jaw,  and  its 
resection  from  the  slight  muscular  attachments  was  agreed  upon.  Indeed, 
all  the  physicians  who  saw  the  patient  gave  an  unfavourable  prognosis 
as  to  the  termination  of  the  case. 

However,  on  the  morning  fixed  for  the  operation,  the  seventh  day  after 
the  injury,  the  condition  of  the  patient  was  entirely  too  precarious  to 
admit  or  justify  any  operation,  and  then  it  was  agreed  to  allow  the 
reparative  powers  of  nature  full  scope,  and  remove  the  sequestra  of  bone 
as  they  became  loosened.  On  this  day  the  patient  was  sinking  very 
rapidly,  but  soon  rallied,  after  a  decided  increase  in  the  amount  of 
stimulants  and  food  given  him.  Unfortunately  this  low  condition  of  the 
patient  hindered  us  from  securing  his  photograph,  as  for  several  weeks  his 
wound  was  considered  necessarily  fatal  by  every  physician  who  saw  him. 
The  patient  during  the  first  week  consumed,  besides  the  food  he  took, 
xij  ounces  of  brandy  per  diem,  but  after  this  period  used  every  day  xx 
ounces  of  brandy,  3  quarts  of  milk,  half  a  jar  of  Valentin's  meat  extract, 
a  pint  of  beef-tea,  and  3  or  4  eggs.  About  1  grain  of  morphia  sulphate 
was  administered  during  the  course  of  24  hours,  and  a  solution  of  the 
phosphates  of  iron,  quinia,  and  strychnia  was  given  from  the  time  of  the 
injury. 

The  splint  shown  in  the  drawing  on  page  97  was  not  applied  until  two 
weeks  after  the  wound  had  been  received,  owing  to  the  difficulty  of  devis- 
ing any  apparatus  of  the  kind,  and  the  time  required  in  its  manufacture. 
The  kind  assistance  of  Dr.  T.  Yardley  Brown,  a  dentist  of  this  city,  and 
Mr.  Van  Reed,  his  student,  not  only  in  inventing  the  apparatus,  but  in 


1878.] 


Muhlenberg ,  Gunshot  Wound  of  the  Face. 


95 


its  entire  manufacture,  made  the  splint  feasible.  The  measurements  for 
the  splint  were  made  by  Dr.  Brown  with  a  great  deal  of  difficulty,  as  an 
ordinary  pair  of  dividers  could  hardly  be  pushed  in  the  mouth,  and  of 
course  no  wax  model  was  practicable. 

Within  two  weeks  after  the  wound  was  received,  the  wound  of  entrance 
had  closed,  but  in  the  subsequent  week  again  broke  open  and  discharged 
some  spicula  of  bone. 

The  discharge  of  pus  from  the  nose,  mouth,  and  external  wounds  was 
excessive,  and  interfered  to  a  certain  extent  with  the  feeding  of  the 
patient.  He  was  forced  to  lie  and  sleep  with  his  head  thrown  far  forward, 
and  to  assume  almost  a  sitting  posture  in  bed,  to  prevent  the  pus  and 
fragments  of  bone,  discharged  into  the  mouth,  from  running  or  falling 
down  his  throat. 

Salicylic  acid  was  applied  topically  to  the  mouth  and  external  wound, 
to  act  as  a  disinfectant  and  correct  the  fetor.  In  the  mouth  it  caused 
considerable  irritation  with  desquamation  of  the  epithelium,  and  on  this  ac- 
count a  solution  of  chlorinated  soda  was  substituted  for  it.  A  solution  of 
boracic  or  carbolic  acid  was  daily  used  to  cleanse  the  wounds  during  the 
entire  sickness.  The  mouth  was  syringed  at  least  every  hour  during  the 
day,  and  almost  as  frequently  at  night,  for  the  mixture  of  pus,  saliva  and 
food  formed  quite  concrete  masses  which  would  not  How  out.  After  the 
wound  of  entrance  had  again  broken  open,  warm  carbolated  water  was 
injected  through  it  into  the  face,  at  least  three  times  a  day.  The  injected 
fluid  ran  out  of  both  nostrils,  the  mouth,  and  the  external  wound  on  the 
opposite  side  of  the  face.  A  large  sinus  at  the  inner  canthus  of  the  left 
eye  was  also  used  for  injection,  and  through  it  large  quantities  of  pus  were 
discharged  by  the  nose  and  mouth.  A  probe  inserted  at  this  opening  fell 
by  its  own  weight  as  far  as  the  roof,  and  occasionally  to  the  floor  of  the 
mouth,  while  it  required  only  the  slightest  effort  to  pass  a  probe  from  the 
right  cheek  to  the  left  nostril. 

This  plan  of  treatment  was  continued  for  two  months,  the  dead  pieces 
of  bone  being  removed  as  fast  as  they  appeared,  when  the  patient  was  at 
last  freed  from  any  discharge  of  pieces  of  bone,  or  symptoms  of  osseous 
inflammation.  Forty  different  pieces  of  bone,  each  larger  than  a  pea. 
were  removed  from  the  face,  nose,  and  mouth  before  convalescence  was 
completed,  and  one  piece  of  lead  about  as  large  as  a  buckshot  was  pried 
out  of  the  left  nostril.  The  effusion  in  the  lids  of  the  left  eye  and  in  the 
eye  itself  was  excessive,  but  the  oedema  was  readily  lessened  by  an  in- 
verted action  of  the  hypodermic  syringe.  A  lump  of  oedematous  flesh, 
as  large  as  a  walnut,  was  present  under  the  same  eye  for  nearly  six 
months. 

TS'ithin  two  months  the  upper  jaw  had  been  gradually  forced  up  to  its 
normal  position,  but  owing  to  the  extreme  loss  of  bone,  had  been  pressed 
back  into  the  mouth  further  than  was  necessary.  Unfortunately  the  ad- 
justment of  straps  to  the  splint  made  it  an  easy  matter  for  the  nurses  to 
alter  the  tension  of  the  different  straps  if  the  patient  complained  of  pain 
on  one  side  of  the  face  or  the  other. 

From  the  time  of  the  adjustment  of  the  splint  (August)  to  the  latter 
end  of  November,  the  patient  wore  it  continuously,  and  hardly  ever  ob- 
jected to  its  presence  in  his  mouth.  The  teeth  of  the  upper  jaw  presented 
an  irregular  position,  which  perhaps  might  have  been  originally  obviated 
if  the  adjustment  of  the  straps  of  the  splint  had  not  been  interfered  with 
by  the  nurses.    In  November  all  the  wounds  had  closed,  except  a  small 


96 


Muhlenberg,  G  unshot  Wound  of  the  Face. 


[July 


communication  in  the  mouth  immediately  behind  the  incisors,  between 
the  nose  and  mouth,  which  gave  rise  to  considerable  annoyance,  as  the 
food  readily  collected  there. 

Since  the  middle  of  December  the  patient  has  been  wearing  an  elegant 
apparatus,  contrived  by  Dr.  T.  Y.  Brown,  to  remedy  the  false  position  of 
his  upper  teeth.  Unfortunately  the  patient  still  continues  wearing  it,  and 
as  I  have  not  seen  him  for  a  month,  cannot  secure  a  drawing  of  it.  It  is 
made  of  a  silver  plate,  accurately  moulded  to  the  upper  jaw,  and  retained 
in  its  position  by  a  clamp  around  the  last  molar.  A  lever,  in  front  of  the 
same  tooth,  working  in  a  joint,  and  having  its  upper  end  attached  by  a 
gum  cord  to  the  same  tooth,  presses  forcibly  upon  the  inner  side  of  the 
last  bicuspid,  and  gradually  throws  it  out.  A  gum  cord,  fastened  around 
the  canine  tooth  of  the  right  side,  pulls  it  back,  as  the  cord  is  attached  to 
a  small  lever  in  the  back  part  of  the  plate.  Since  the  adaptation  of  this 
splint  the  position  of  the  teeth  has  become  nearly  normal,  and  at  some 
future  day  we  may  give  an  account  of  the  amended  mouth  and  splint. 

Since  the  beginning  of  this  year  the  patient  has  been  able  to  use  his 
upper  jaw  nearly  as  well  as  before  the  injury,  although  the  union  is  not 
perfect.  He  can  eat  and  chew  any  kind  of  food.  The  communication 
between  the  mouth  and  nose  has  entirely  closed.  The  right  side  of  the 
face  is  very  slightly  disfigured,  and  even  the  entire  absence  of  the  orbital 
portion  of  the  superior  maxilla  of  this  side,  which  was  removed  piecemeal, 
is  hardly  noticeable.  The  hollow  along  the  edge  of  the  lower  lid  is  not 
marked,  still  the  removal  of  this  bone  has  given  rise  to  an  epicanthus  of 
the  inner  angle  of  the  eye.  There  are  a  good  many  scars  on  the  left  side 
of  the  face,  and  vision  is  totally  lost  in  the  left  eye. 

With  the  exception  that  the  lachrymal  bone  has  been  removed,  the  floor 
of  the  left  orbit  is  entire ;  still  it  is  all  depressed  some  distance  below  its 
normal  level. 

The  nose  is  considerably  flattened,  and  pervious  only  on  the  one  side. 
Vision  in  the  right  eye,  hindered  at  first  by  the  epicanthus,  is  now  nearly 
as  good  as  before  the  accident. 

During  the  entire  period  of  sickness  there  were  no  symptoms  of  any 
erysipelatous  or  pyemic  troubles. 

Injuries  of  this  kind  are  so  rare  that  scarcely  any  allusion  is  made  to 
them  in  the  text-books. 

The  inferences  we  have  drawn  have  been  the  following  : — 

No  matter  how  severe  the  injury  of  the  upper  part  of  the  face,  owing 
to  the  excessive  vascularity  of  the  part,  the  reparative  powers  of  nature 
are  very  decided,  and  the  removal  of  any  apparently  sound  pieces  of  bone 
seems  unjustifiable.    Good  nursing  is  a  sine  qua  non. 

The  subsequent  union  will  probably  be  osseous. 

The  clanger  from  erysipelas  can  be  readily  guarded  against.  Great 
attention  must  be  paid  to  cleanliness,  and  antiseptics  cannot  be  dispensed 
with. 

The  surgery  of  thesa  parts  of  the  body  must  be  conservative,  and  must 
be  varied  according  to  the  exigencies  of  each  case. 

The  wood-cut  of  the  splint  represents  a  full  view  from  behind.  The 
cup-shaped  body  of  this  splint  is  made  of  silver,  while  the  outer  band  is 


1878.]        Muhlenberg,  Gunshot  Wound  of  the  Face.  97 

of  brass,  and  firmly  welded  to  it  by  hard  solder,  so  that  the  entire  splint 
is  and  acts  as  a  solid  body.  The  splint  on  being  applied  acts  as  a  rest  for 
the  teeth,  which  are  prevented  from  being  pressed  out  by  the  rim.  The 
adjustment  of  the  splint  is  easy.  The  patient  should  wear  a  night-cap 
made  of  some  stout  material.  At  b  o  and  r  s  are  firmly  fastened  gum 
bands  which  pass  directly  behind  the  head ;  at  the  same  places,  which  are 
immediately  in  front  of-  the  ear,  similar  bands  are  attached,  which  run  up 
over  the  temples,  and  at  d  m  and  n  p  gum  bands  are  joined,  which  lead  up 
on  each  side  of  the  nose  and  pass  to  the  front  part  of  the  head. 


After  the  body  of  the  splint  is  introduced  into  the  mouth,  presupposing 
a  comminuted  or  bad  fracture  of  the  upper  jaw,  and  after  the  readjust- 
ment of  the  fragments,  the  bands  at  b  o  and  r  s,  which  run  behind  the 
head,  are  tightened  and  pulled  back,  and  of  course  draw  back  the  entire 
splint  and  upper  jaw,  if  there  has  been  any  anterior  displacement  of  it. 
The  bands  running  over  the  temples  are  then  pinned  or  sewed  fast  to  the 
night-cap,  and  elevate  the  posterior  part  of  the  band  of  the  splint,  which 
is  outside  the  mouth,  and  naturally  the  posterior  part  of  the  body  of  the 
splint  in  the  patient's  mouth,  as  the  splint  is  supposed  to  be  one  solid 
body.  The  bands  running  over  the  face,  on  each  side  of  the  nose,  when 
fastened,  serve  to  raise  the  anterior  part  of  the  splint.  With  these  six 
straps  we  can  then  produce  any  effect  we  please,  and  can  raise  or  loosen  a 
single  one,  or  a  pair  of  straps,  according  to  circumstances.  The  combined 
effect  of  them  is  to  raise  and  retract  the  upper  jaw,  and  this  is  very  readily 
effected.  By  using  the  elastic  straps,  change  in  the  tension  can  be 
readily  made,  and  besides,  the  elastic  nature  of  the  India-rubber  serves 
steadily  to  produce  the  effect  desired.  The  great  objection  to  this  splint  is 
the  ease  with  which  these  straps  can  be  tightened  or  loosened  at  the  desire 
of  the  patient. 

No.  CLI  July  1878.  7 


98 


Gun  drum,  Extirpation  of  the  Scapula. 


[July 


Article  VIII. 

Case  of  Extirpation  of  the  Scapula  with  a  Portion  of  Clavicle 
and  Entire  Arm.    By  F.  Gundrum,  M.D.,  of  Ionia,  Michigan. 

On  December  2,  1876,  I  was  summoned  to  amputate  an  arm.  Accom- 
panied by  Dr.  S.  V.  Romig,  who  kindly  volunteered  to  assist  me,  I  re- 
paired to  the  patient's  house,  and  obtained  the  following  history  of  the 

case  : — 

On  December  10,  1876,  the  boy  John  was  out  hunting,  when,  while 
crossing  a  log,  his  gun  accidentally  discharged,  and  the  load  took  effect  in 
the  arm  between  the  shoulder-  and  elbow-joints.  The  wound  was  dressed 
with  adhesive  strips,  and  a  roller  bandage  applied  from  the  shoulder  into 
the  elbow-joint.  No  foreign  bodies  were  extracted.  After  a  few  hours 
the  hand  began  to  swell  and  turn  dark,  and  became  very  painful.  The 
swelling  increased,  the  colour  grew  darker,  and  during  the  night  the  boy 
became  delirious  and  very  feverish.  Next  morning  the  forearm  was  found 
to  be  intensely  swollen,  "  black,"  and  perfectly  free  from  all  pain,  and  the 
patient  was  apparently  sinking  rapidly.  On  the  third  day.  at  a  second 
consultation,  it  was  deeided  nothing  could  be  done  at  present  but  to  keep 
patient  alive  by  nutritious  food,  etc.  His  physicians  did  not  see  him 
again.  The  patient  was  now  attended  by  an  old  gentleman  who  had 
served  as  nurse  in  the  German  army  many  years  ago.  As  the  hoy  did 
not  succumb  to  his  injuries,  after  being  abandoned  for  several  days,  his 
father  asked  to  have  me  called  in  to  see  the  case. 

Present  condition :  The  stench  of  the  room  is  extremely  offensive ;  patient 
is  propped  up  with  pillows  ;  his  general  aspect  is  that  of  extreme  exhaus- 
tion. He  looks  blanched  and  haggard  ;  face  cool  and  covered  with  large 
drops  of  perspiration;  nose  pinched.  Respirations  40;  pulse  130,  and 
very  gaseous  and  dicrotic.  He  still  takes  some  nourishment.  But  for 
last  few  days  his  appetite  has  been  failing. 

His  tongue  does  not  look  as  we  usually  find  it  with  above  group  of  symp- 
toms. It  is  moist  and  covered  with  a  slight,  white  fur,  but  not  sufficiently 
thick  to  prevent  the  tongue  being  seen  through  it.  Bowels  are  moved 
daily ;  urine  highly  loaded.  Faculties  have  been  clear  for  several  days. 
Since  the  fifth  day,  the  wound  had  been  dressed  with  common  sweet  oil. 

The  arm  to  eight  inches  above  elbow,  including  fingers  and  hand,  was 
intensely  dark  and  hard,  "  mummified,"  and  lay  across  patient's  body. 
Above  this  on  the  anterior  aspect  and  a  little  inwards  the  bone  was  bare 
and  dead.  At  the  inner  side  up  to  the  axilla  the  tissues  seemed  to  be  in  a 
soft  sloughing  mass.  On  the  outer  side  the  soft  tissues  were  mummified  to 
within  four  inches  of  the  shoulder-joint,  where  the  bone  was  bare  of  all  soft 
tissues  and  periosteum,  and  dead.  The  capsular  ligament  was  exposed 
on  outer  side  and  filled  with  greenish-looking  pus.  The  sloughing  process 
had  not  ceased  here,  but  extended  sufficiently  to  expose  the  acromial  end 
of  clavicle,  the  spine  of  the  scapula,  a  small  portion  of  supra-spinous  fossa, 
and  about  half  of  scapula  below  spine,  the  infra-spinous  fossa.  In  these 
parts  the  scapula  was  denuded  of  its  periosteum.  On  the  shoulder  the 
line  of  demarcation  was  formed,  and  in  most  places  the  dead  tissues  had 
separated,  but  in  the  axilla  and  back  there  had  been  no  effort  at  separation. 

Wishing  to  find  if  there  were  any  living  tissues  on  inner  side  of  humerus, 
with  the  aid  of  a  pair  of  dressing  forceps  and  scissors,  I  began  to  clear 


1878.] 


Gundrum,  Extirpation  of  the  Scapula. 


99 


tlie  tissues  away  for  about  four  or  five  inches  below  axilla.  I  soon  came 
across  a  charge  of  shot,  together  with  some  clothing,  and  about  the  inner 
border  of  biceps,  i.  e.  where  the  biceps  should  have  been,  I  encountered 
something  which  gave  the  boy  pain.  It  proved  to  be  the  brachial  artery, 
still  intact,  but  without  pulsation ;  it  was  quite  firm  in  consistence,  and 
its  Avails  were  in  apposition.  After  satisfying  myself  that  its  lumen  was 
entirely  obliterated,  and  no  chance  of  hemorrhage,  I  divided  it.  The 
least  traction  on  the  vessel  caused  excruciating  pain.  The  remaining 
tissues  were  now  divided,  and  the  bone  sawed  off  at  about  four  to  five 
inches  from  its  head.  The  operation  was  purposely  made  through  dead 
tissues,  as  the  loss  of  a  few  ounces  of  blood  might  have  proved  fatal  to  the 
patient,  or  the  opening  of  sound  tissue  prove  an  avenue  for  pysemic  in- 
fection. He  was  now  ordered  the  following  treatment :  R.  Quiniae  sulph.  5j  5 
tr.  ferri  chloridi,  3ijss;  yini  Oporto,  ^viiss. — Mix.  Sig. — ^ss  once  in  four 
hours  ;  also  one  ounce  port  wine  every  four  hours,  and  to  have  the  most 
nutritious  and  digestible  food.  As  a  local  application  the  following  lotion 
was  ordered:  R.  Acid,  carbolic,  ;  glycerin  oe,  ,^xv. — Mix.  An  ounce 
of  this  to  be  put  into  a  pint  of  water  and  applied  warm  on  soft  linen  cloths, 
and  covered  with  oiled  silk. 

On  the  27th  I  visited  him  and  thought  him  beyond  hope.  The  next  day 
his  fever  came  up,"  and  a  homoeopathic  friend  advised  that  my  treatment 
was  too  stimulating  ;  had  brought  up  the  boy's  fever,  and  substituted  aconite 
and  belladonna  solutions.  Patient  was  clammy,  gasping  for  breath;  pulse 
150,  very  feeble  ;  with  cough  and  stitch  in  left  side;  temp,  not  taken. 
Dr.  Saur  now  visited  the  patient  daily  for  me.  The  line  of  demarcation 
had  formed  and  nearly  all  the  dead  tissue  had  sloughed  away. 

He  was  given  brandy  every  few  minutes,  until  he  had  somewhat  ral- 
lied, and  plenty  of  nourishment.  The  quinia  and  iron  mixture  were  con- 
tinued. From  this  time  he  improved  slowly  but  steadily.  All  the  dead 
tissue  separated  within  ten  days,  and  in  three  weeks  he  was  walking 
around  in  the  house. 

On  January  2Gth,  accompanied  by  Dr.  Romig,  I  visited  the  patient, 
carefully  examined  the  injured  limb,  and  made  the  following  notes  : — 

The  remaining  portion  of  humerus  was  dead.  Over  the  capsular  liga- 
ment, on  inner  side,  there  were  some  small  islands  of  granulation  tissue. 
The  end  of  the  clavicle  was  necrosed  for  1  \  inches.  The  greater  part  of 
supra-spinous  fossa,  with  two-thirds  of  spine,  and  one-half  of  the  infra- 
spinous  fossa  of  scapula  were  denuded  of  periosteum.  The  inner  angle 
and  border  for  1  to  1-^  inches  were  covered  by  skin.  The  lower  angle 
and  from  about  2^  to  3  inches  above  the  external  border  were  covered 
irregularly,  though  with  its  normal  tissues.  In  the  supra-spinous  fossa 
the  scapula  was  not  only  denuded  of  periosteum,  but  was  also  carious. 
As  it  seemed  but  very  little  of  the  scapula  was  in  a  healthy  condition,  and 
of  no  use  if  allowed  to  remain,  I  determined,  with  the  full  concurrence  of 
Drs.  Romig  and  Saur,  to  remove  the  scapula  entire  with  the  carious 
end  of  the  clavicle,  and  remaining  portion  of  dead  humerus. 

Operation. — The  patient  was  given  two  ounces  of  French  brandy,  and 
when  he  felt  its  influence  he  was  put  upon  an  extension  table,  and  Dr. 
Saur  administered  the  ether. 

My  first  incision  extended  from  about  the  lower  two-thirds  of  scapula, 
where  the  bone  began  to  be  covered  with  tissues  to  its  inferior  angle,  and 
another  divided  the  tissues  over  the  superior  angle  a  little  above  the  spine. 
I  now  took  Dr.  Sayre's  periosteal  knife,  hoping  in  this  way  to  avoid  ves- 


100    Peters,  Excision  of  Entire  Scapula  for  Cancerous  Disease.  [ July 


sels  and  save  all  the  blood  I  could,  and  peeled  up  the  tissues,  hugging  the 
bone,  taking  along  the  periosteum  wherever  there  was  any.  I  thus  freed 
the  external  border  near  the  inferior  angle  and  inner  border.  Coming 
now  to  the  superior  border  and  the  supra-spinous  fossa,  I  peeled  out  the  tis- 
sues in  the  same  way.  I  then  made  an  incision  over  the  clavicle  as  far  as 
the  necrosed  tissues  extended,  and  dissected  them  away  carefully,  so  as  to 
avoid  wounding  any  important  vessels.  I  now  turned  up  the  inner  border 
and  enucleated  the  scapula.  I  thus  worked  from  below  upwards  until  I 
reached  the  coracoid  process  ;  I  then  sawed  off  about  one  and  three-fourths 
inches  of  the  outer  end  of  clavicle,  and  removed  it  with  the  scapula  and 
humerus. 

During  the  operation  four  vessels  were  ligated,  and  some  eight  or  ten 
smaller  ones  twisted.  When  I  had  removed  the  shoulder  blade,  etc.,  I 
found  I  had  not  enough  tegument  to  cover  the  enormous  wound.  There 
not  being  much  time  for  reflection,  as  my  patient  looked  more  dead 
than  alive,  I  rapidly  dissected  up  the  skin  and  superficial  fascia  sufficiently 
to  slide  them  together  to  form  an  integumentary  covering.  The  wound 
was  washed  out  with  carbolized  water,  and  after  closing  with  silk  stitches 
was  dressed  with  lint  and  a  thick  layer  of  cotton-wool. 

The  wound  healed  quickly,  the  patient  was  up  in  a  week,  and  made  an 
excellent  and  complete  recovery. 

From  the  periosteum  that  was  peeled  from  the  scapula  at  its  lower 
angle,  superior  angle,  and  inner  border,  considerable  bone  formation  was 
reproduced  within  eighteen  months. 


Article  IX. 

Case  of  Excision  of  the  Entire  Scapula  for  Cancerous  Disease. 
Recovery  of  the  Patient  with  a  Useful  Arm.  By  George  A. 
Peters,  M.D.,  Attending  Surgeon  Xew  York  Hospital,  Xew  York. 

Charles  Smith,  England,  a3t.  42,  cabinet-maker,  was  admitted  into 
the  New  York  Hospital  January  3d,  1878,  with  the  following  history: 
Eighteen  months  ago  he  noticed  slight  stiffness  in  the  movements  of  the 
right  arm,  accompanied  by  a  moderate  swelling  of  the  corresponding  shoul- 
der. It  caused  him  no  pain,  only  a  slight  discomfort  on  certain  motions 
of  the  shoulder-joint,  or  when  he  lay  upon  the  affected  side.  These  symp- 
toms remained  about  the  same  until  three  months  before  admission,  when 
he  experienced  more  difficulty  in  using  the  arm,  and  was  not  able  to  work 
at  his  trade  with  his  usual  facility.  At  this  time  he  also  began  to  have 
severe  pain,  lasting  for  a  few  minutes  if  the  shoulder  were  struck  or  pressed 
upon.  Within  the  past  three  months  the  tumour  has  commenced  to  grow 
rapidly.  General  health  good;  no  family  history  pointing  towards  cancer. 
Is  not  aware  that  he  has  ever  overstrained  or  injured  the  arm.  Exami- 
nation on  admission  showed  a  tumour  of  the  right  shoulder  situated  upon 
and  above  the  spine  of  the  scapula.  The  tumour  was  not  distinctly  cir- 
cumscribed, and  had  a  somewhat  elastic  feel;  was  not  movable.  There 
were  two  points  of  tenderness,  one  upon  the  outer  and  the  other  upon  the 
inner  portion  of  the  tumour;  four  and  a  half  inches  apart.    The  measure- 


1878.]  Peters,  Excision  of  Entire  Scapula  for  Cancerous  Disease.  101 


ments  were  a?  follows:  On  diseased  side,  vertical  circumference  around 
the  axilla  and  over  the  highest  point  of  the  tumour  was  twenty  inches. 
Measurement  upon  the  sound  side  was  seventeen  inches.  The  skin  over 
the  surface  of  the  tumour  was  congested,  and  the  surface  temperature  was 
increased.  Motion  of  the  shoulder-joint  not  much  impeded,  though  on 
circumduction  the  entire  shoulder  is  raised.  Aspirator  needle,  number  4, 
M  as  inserted,  drawing  off  only  blood. 

In  consultation  with  my  colleagues  at  the  hospital,  it  was  determined 
that  the  tumour  was  probably  malignant,  involving  a  portion  of  the  sca- 
pula. It  was  also  determined  that  the  entire  scapula  should  be  removed 
rather  than  to  lea  ve  any  portion  of  it  behind.  The  operation  was  performed 
January  1 1th.  1878.  Patient  was  etherized.  Carbolic  spray  was  used,  and 
all  the  details  of  Lister's  antiseptic  method  were  faithfully  carried  out.  A 
horizontal  incision  through  the  skin  was  made  over  the  centre  of  the  tumour, 
along  the  spine  of  the  scapula,  from  the  acromion  process  to  its  superior 
angle.  Some  fibres  of  the  trapezius  and  deltoid  muscles  were  divided 
upon  a  director,  thus  exposing  the  surface  of  the  tumour,  which  was  found 
to  involve  the  spine  and  supra-spinous  fossa.  A  vertical  incision  was  now 
carried  from  the  middle  of  the  transverse  cut  down  to  the  inferior  angle  of 
scapula.  The  skin  flaps  were  rapidly  dissected  up  and  reflected  to  either 
side.  The  posterior  border  of  the  scapula  was  then  freed  by  dividing  the 
trapezius,  rhomboidei,  and  the  levator  anguli  scapula?  muscles,  at  their  at- 
tachments to  the  bone,  which  was  then  lifted  up  and  tilted  forward.  The 
subscapularis  muscle  was  stripped  from  the  under  surface  of  the  scapula  by 
a  few  rapid  sweeps  of  the  knife,  and  allowed  to  drop  down  on  the  floor  of 
the  cavity.  The  anterior  border  of  the  scapula  was  now  freed  from  its 
muscular  attachments.  The  shoulder-joint  was  opened  from  behind  and 
above,  and  completely  disarticulated.  In  endeavouring  to  separate  the 
acromion  process  at  its  articulation  with  the  clavicle,  it  was  found  so  soft 
from  cancerous  infiltration  that  the  knife  went  directly  through  the  bone. 
The  distal  piece,  three-quarters  of  an  inch  in  length,  was  subsequently 
removed.  There  was  difficulty  in  reaching  the  coracoid  process  from  the 
outside,  so  the  almost  detached  scapula  was  forcibly  raised  and  turned 
upon  itself,  when  a  few  strokes  of  the  knife  released  it  from  the  ligament 
and  muscle  which  bound  it  down. 

Carbolized  catgut  ligatures  were  applied  to  the  supra  scapular,  the  pos- 
terior scapular,  and  the  dorsalis  scapular  arteries.  The  subscapular  artery 
was  not  divided.  Several  small  bleeding  points  were  secured  in  the  same 
manner.  Four  drainage  tubes  were  inserted:  the  edges  of  the  wound  were 
brought  together  and  secured  with  carbolized  catgut  sutures,  and  the  cavity 
injected  with  a  solution  of  carbolic  acid,  one  to  thirty.  Lister's  dressing 
was  applied,  the  arm  carried  to  the  side  and  crowded  well  up  towards  the 
acromial  end  of  the  clavicle.    Forearm  flexed  and  supported  in  a  sling. 

An  hour  or  so  after  the  operation,  blood  was  found  oozing  freely  through 
the  dressings,  which  were  loosened  under  the  carbolic  spray,  and  the  sutures 
removed.  The  source  of  hemorrhage  was  found  to  be  the  supra-scapular 
artery,  from  which  the  ligature  had  slipped.  The  vessel  was  secured,  the 
wound  closed,  and  the  dressings  reapplied.  Patient  rallied  well  from  the 
operation. 

January  12.  Twenty-four  hours  after  the  operation  the  dressings  were 
removed.  There  was  considerable  sero-sanguineous  discharge.  A.  M. 
Pulse  130,  temp.  101.    P.M.  Pulse  134,  temp.  101.6. 

13th.  Again  dressed.    Discharge  no  longer  sanguineous.    No  inflamma- 


102    Peters,  Excision  of  Entire  Scapula  for  Cancerous  Disease.  [July 


tory  redness.  A.M.  Pulse  130,  temp.  99.  P.M.  Pulse  132,  temp. 
101.6. 

lUh.  Dressings  again  changed.    A.M.  Pulse  130,  temp.  101.2.  P.M. 

Pulse  126,  temp.  100.6. 

ICyth.  Dressings  changed.  Discharge  very  moderate.  No  inflamma- 
tory redness.  Sutures  were  all  absorbed,  and  edges  of  wound  consequently 
gaped  somewhat. 

11th.  Dressings  again  changed.  A.M.  Pulse  114,  temp.  100.4.  P.M. 
Pulse  112,  temp.  102.4. 

This  was  the  highest  point  of  temperature  reached  during  the  progress 
of  the  case.  The  discharge  from  the  wound,  which  was  at  no  time  very 
great,  gradually  diminished.  Owing  to  the  early  melting  away  of  the 
gut  sutures,  there  was  primary  union  only  in  a  portion  of  the  horizontal 
incision.  The  flaps  were  kept  in  position  as  well  as  possible  by  compresses 
and  bandages,  and  the  remainder  of  the  cure  was  accomplished  by  granu- 
lation. The  Lister  dressings  were  continued  until  the  14th  of  February, 
when  simple  open  dressings  were  applied  to  the  small  ulcer  which  remained. 
Up  to  February  4th  the  head  of  the  humerus  could  be  seen  deep  do  n  in 
the  superior  angle  of  the  wound,  after  which  time  it  rapidly  disappeared 
from  view  as  the  sinus  leading  to  it  filled  up  with  granulations. 

March  21.  Patient  was  discharged  cured.    He  was  aide  to  dress  and 

undress  himself  somewhat  awk- 
wardly: to  carry  the  right  hand  to 
the  mouth,  also  behind  the  back, 
and  could  elevate  the  arm  from  the 
side  to  a  considerable  degree.  The 
accompanying  wood-cut  will  give 
a  good  idea  of  the  comparatively 
slight  deformity  which  remains 
after  so  extensive  an  excision. 

Although  on  the  whole  well 
pleased  with  the  Lister  dressings, 
I  found  great  difficulty,  owing  to 
their  cumbrous  thickness,  in  closely 
adapting  the  flaps  during  the  pro- 
cess of  healing.  In  a  similar  ease 
I  should  use  either  carbolized  silk, 
or  even  the  silver  wire  suture,  in 
preference  to  catgut. 

After  removal,  the  tumour  was 
found  to  involve  at  least  seven- 
eighths  of  the  spine  of  the  scapula; 
from  and  including  the  acromion 
process  to  the  smooth  triangular 
surface  over  which  the  trapezius 
muscle  glides.  The  supra-spinous  fossa  was  slightly  involved ;  the  infra  - 
spinous  fossa  was  not  invaded. 

From  a  microscopic  examination  of  slices  from  the  tumour,  it  appeared 
to  be  a  medullary  carcinoma,  originating  probably  in  the  spongy  tissue  of 


1878.]     Jacobi,  Sphygmograpliic  Experiments  on  the  Brain.  103 


the  scapula,  and  undergoing  rapid  colloid  degeneration.  This  diagnosis 
was  verified  by  Dr.  W.  F.  Bull  and  Dr.  G.  L.  Peabody,  both  of  whom 
examined  the  tumour. 

It  is  not  my  intention  to  write  a  history  of  the  operations  involving  a 
removal  of  the  scapula,  in  part  or  entire,  but  simply  to  put  this  case  on 
record  as  a  contribution  to  the  annals  of  conservative  surgery.  In  the 
American  Journal  of  Medical  Sciences  for  October,  1868,  may  be  found 
a  carefully  prepared  paper  by  Dr.  Stephen  Rogers,  of  New  York,  in  which 
he  gives  the  histories  of  fifty-six  operations,  involving  the  loss  of  more  or 
less  of  the  scapula.  Up  to  that  time,  and  including  Dr.  Rogers's  case, 
there  had  been  "  known  to  the  history  of  surgery  but  nine  cases  of  exsection 
of  the  entire  scapula,  with  preservation  of  the  arm."  The  records  of  what- 
ever operations  of  this  kind  may  have  been  done  since  the  publication  of 
Dr.  Rogers's  paper,  are  scattered  through  the  pages  of  medical  journals, 
and  have  not.  in  so  far  as  I  know,  been  tabulated. 

In  conclusion,  I  would  state  that  I  last  saw  my  patient  April  21st,  1878, 
at  which  time  there  appeared  to  be  no  signs  of  a  return  of  the  disease 
about  the  shoulder.  There  was  also  an  increase  in  the  power  and  extent 
of  motion. 


Article  X. 

Sphygmographic  Experiments  upon  a  Human  Brain,  exposed  by  ax 
Opexixg  ix  the  Cranium.  By  Mary  Putnam  Jacobi,  M.D.,  of  New 
York. 

Josie  Nolan,  aged  ten,  a  very  healthy  Irish  boy.  had,  eighteen  months 
previous  to  observation,  fallen  and  fractured  his  skull  in  the  right  fronto- 
parietal region.  According  to  the  mother's  account,  he  remained  insen- 
sible for  two  hours  ;  but  recovered  consciousness  about  two  hours  after 
the  fragments  of  broken  bone  had  been  removed  by  the  trepan.  The 
mother  insists  that  from  that  time  the  wound  healed  rapidly,  and  that  the 
child  presented  no  morbid  symptoms,  not  even  fever.  The  history  is  evi- 
dently imperfect.  At  present  there  is  an  opening  in  the  cranial  bones.  m2\ 
inches  in  the  long  diameter,  1^-  inches  transversely.  The  opening  is  situ- 
ated in  the  right  fronto-parietal  regions,  about  2  inches  distant  from  the 
sagittal  suture,  towards  which  the  long  diameter  is  inclined  at  an  acute 
angle.  The  opening  is  covered  by  a  membrane,  much  thicker  at  the 
sides  near  the  bones  than  in  the  middle.  It  is  to  be  presumed  that  the 
central  portion  consists  exclusively  of  dura  mater,  which,  near  the  bony 
margin,  is  thickened  by  the  addition  of  the  remains  of  periosteum.  The 
centre  of  this  membranous  covering  is  habitually  somewhat  depressed  be- 
low the  level  of  the  cranial  bones,  but  rises  and  falls  in  regular  pulsations 
synchronous  with  those  of  the  radial  artery.  Ordinarily,  the  efTect  of 
respiration  is  only  distinctly  seen  in  the  sphygmographic  trace  ;  but,  on 
forced  inspiration,  the  membranes  are  clearly  seen  to  descend  still  further 
below  the  level  of  the  bones,  and  on  forced  expiration  to  bulge  above  it. 


104        J  AC  obi,  Sphygmographic  Experiments  on  the  Brain.  [July 


Pressure  upon  the  brain  through  these  membranes  causes  no  appreciable 
effect  even  on  the  pulse,  and  the  boy,  who  has  all  the  activity  of  his  age, 
has,  so  far,  never  experienced  the  least  inconvenience  from  this  partial 
exposure  of  the  brain.  Under  no  circumstances,  of  digestion,  exercise,  or 
the  influence  of  the  various  drugs  administered  during  the  experiment, 
was  any  change  noticed  in  the  colours  of  the  membranes  indicating  in- 
creased vascularity  in  them.  After  exercise,  they  sometimes  are  bulging, 
but  not  always,  and  the  effect  of  a  temporary  exertion  rapidly  disappears. 
When  the  boy  is  in  a  recumbent  position,  the  level  of  the  membranes  is 
always  higher  than  during  the  vertical  position,  whatever  the  level  in 
the  lntter  might  be,  or  from  whatever  cause  it  had  been  effected.1 

The  case  offered  a  unique  opportunity  for  the  study  of  conditions  affect- 
ing intra-cranial  pressure.  For  this  purpose,  Mahomed's  sphygmograph 
was  adjusted  to  the  head  of  the  boy,  in  such  a  manner  that  the  lever  pad 
rested  on  the  thin  central  portions  of  the  membranes,  the  rest  upon  the 
bones,  and  steadied  by  an  assistant.  The  adjustment  was  always  made 
with  the  boy  in  a  recumbent  position,  the  head  but  slightly  elevated  upon 
a  pillow. 

Before  interpreting  the  traces,  it  is  necessary  to  notice  in  what  respects 
these  must  be  expected  to  differ  from  those  obtained  from  the  expansion  of 
an  artery.  It  is  obvious  that  the  pulsating  encephalon  in  our  case  differs 
from  the  pulsating  artery  :  1st,  by  its  greater  proximity  to  the  heart ;  2d, 
by  its  vertical  position  over  the  heart ;  3d,  by  the  immensely  greater  sur- 
face receiving  the  shock  of  the  cardiac  systole,  and  through  which  must 
be  disseminated  the  tidal  wave  of  blood ;  4th,  by  the  greater  volume  of  blood 
thrown  against  this  surface  ;  5th,  by  the  greater  freedom  allowed  to  the 
excursion  of  the  part  of  the  brain  exposed ;  6th,  by  the  greater  slowness 
with  which  its  mass  could  collapse  upon  the  blood  wave.  The  trace  from 
the  artery  corresponds  to  the  movement  of  the  entire  mass  of  fluid  contained 
in  it.  But  while  the  pulsations  of  the  encephalon  are  due  exclusively  to 
the  influx  of  arterial  blood,  this  fluid  is  only  one  of  three  which  are  moving 
simultaneously  in  the  pulsating  mass,  the  others  being  the  venous  blood 
and  the  cephalo-rachidian  fluid.  7th.  the  final  difference  to  be  noticed  in 
the  much  greater  influence  of  respiration  upon  the  amount  of  blood  con- 
tained at  a  given  moment  in  the  brain,  as  compared  with  that  contained 
at  the  same  moment  in  the  radial  artery. 

These  various  circumstances  will  each  have  a  specific  effect  upon  the 
sphygmograpliic  trace.  Thus,  the  first  five  peculiarities  enumerated  will 
combine  to  give  a  much  greater  amplitude  to  the  curve,  or  an  immense 
increase  in  the  height  of  the  ascension  line. 

Owing  to  the  fourth  circumstance,  the  height  of  the  tidal  wave  above 
the  base  of  the  percussion  stroke  will  be  greater ;  for,  according  to  Ma- 

1  Since  writing  this  paper  I  have  seen  an  article  in  the  Centralblatt  for  1S77,  describ- 
ing analogous  experiments  upon  a  woman's  brain  exposed  by  carcinoma.  The  experi- 
ments did  not  test  the  influence  of  drugs ;  but  the  conclusions  so  far  as  regards  the 
normal  movements  of  the  brain  agree  with  mine.  See  Centralblatt,  Mai  12,  1ST7. 
Giacomini  u.  Masso,  Beweg.  des  Gehirns. 


1878.]    Jacob i,  Sphygmographic  Experiments  on  the  Brain.  105 


homed,  "  this  height  indicates  the  amount  of  blood  forced  into  the  arterial 
system  at  each  ventricular  systole." 1  From  the  sixth  peculiarity,  the 
tidal  wave  should  be  more  sustained.  On  account  of  the  third  character, 
there  should  be  few  oscillations  from  secondary  waves ;  thus,  dicrotic  and 
elasticity  oscillations  should  be  little  marked.  On  the  other  hand,  the 
multiplication  of  resistances  offered  in  the  brain  by  fulness  of  its  veins,  or 
tonic  contraction  of  its  arteries,  should  render  obliquity  of  the  percussion 
stroke,  and  even  anacrotismus  of  the  ascending  line  more  frequent.  Fi- 
nally, from  (seventh)  the  greater  influence  upon  intra-cranial  circulation 
exercised  by  the  aspirating  force  of  inspiration,  a  much  greater  depres- 
sion should  occur  at  the  moment  of  inspiration  in  the  ligne  oV  ensemble. 

The  foregoing  characters  are  all  exhibited  by  the  traces.  The  en- 
cephalic expansions,  as  uninfluenced  by  medicines,  are  shown  in  Trace  No. 
I. ;  also,  in  Trace  No.  VI.  before  the  administration  of  atropia,  and  No.  X. 
before  coffee,  and  under  the  double  influence  of  exercise  and  the  digestion 
of  a  full  meal. 


Trace  I. 


Under  pressure  5. 


Description  Trace  Xo.  I.  exhibits  a  peculiarity  not  observable  in 

Traces  VI.  and  X. ;  it  possesses  an  anacrotic  elevation,  or  an  elevation  on 
the  ascending  line.2 

This  is  described  by  Mendel3  as  the  character  of  the  "  pulsus  tardus." 
In  his  schema,  Landois  succeeded  in  producing  "  anacrotismus"  under  one 
of  three  conditions,  namely,  when  the  exit  opening  of  the  schematic  artery 
is  narrowed  ;  when  the  elasticity  of  its  walls  is  diminished  ;  and  when, 
from  increased  volume  of  its  contents,  the  internal  tension  is  increased. 
Each  of  these  conditions  renders  the  distension  of  the  tube  by  the  systolic 
wave  more  difficult,  hence  prolongs  the  period  of  distension.  Eulenberg 
shows  that  an  anacrotic  elevation  may  be  obtained  by  compression  of  the 
artery  beyond  the  point  at  which  the  sphygmograph  is  applied. 

The  other  characters  of  this  trace  are,  the  well-developed  tidal  wave,  or 
curve  intervening  between  the  percussion  stroke  and  the  aortic  notch,  and 
which,  according  to  Mahomed,  indicates  the  mass  which  has  been  thrown 
into  the  arteries  by  the  cardiac  systole ;  2d,  the  deep  inspiratory  depres- 

1  Med.  Times  and  Gaz.,  vol.  i.  1S72,  p.  129. 

3  Elevation  first  studied  experimentally  by  Landois.  Die  Lenre  vom  arterien  Puis, 
Berlin,  1872. 

3  Arch.  Yirch.,  Bd.  66,  p.  260.    See  also  Eulenberg,  Arcb.  Yircb.,  Bd.  45, 1869. 


106        Jacobi,  Sphygmographic  Experiments  on  the  Brain.  [July 


sion ;  3d,  the  dicrotic  elevation  is  slight,  but  more  marked  than  in  other 
traces. 

Interpretation — These  characters,  together  with  the  short  but  vertical 
percussion  stroke,  indicate  increased  cerebral  resistance  with  a  large  volume 
of  blood  in  active  circulation.  The  larger  the  mass  to  be  aspired  into  the 
thorax  at  inspiration,  the  more  marked  must  be  the  depression  in  the  line 
of  cerebral  expansions,  or  the  ligne  d 'ensemble  of  the  trace.1  The  slightly 
increased  dicrotism  in  the  trace  is  to  be  referred  to  the  state  of  the 
membranes,  which  were  depressed,  and  flaccid,  not  tense  or  bulging.  It 
was  clear,  therefore,  that,  notwithstanding  the  considerable  tidal  wave, 
the  brain  was  not  at  the  time  distended.  In  another  trace,  taken  when 
the  membranes  were  tense  and  bulging,  dicrotism  had  entirely  disappeared. 
It  is  to  be  inferred  that  the  tonic  resistance  of  the  bloodvessels  was  at  this 
time  great.  Such  a  condition  would  at  once  explain  the  great  resistance 
offered  to  the  cardiac  systole,  causing  anacrotismus,  and  the  diminished 
tension  of  the  membranes,  permitting  slight  dicrotismus.  The  radial  pulse 
showed  high  tension,  and  complete  absence  of  dicrotism. 

Hence,  important  corollary,  we  must  conclude  that  intracranial  pres- 
sure (such  as  would  distend  the  membranes)  is  not  necessarily  in  propor- 
tion to  the  tension  of  the  cerebral  bloodvessels,  or  to  the  height  of  their 
tidal  wave,  but  may  be  just  the  reverse. 


Trace  II. 


Pressure  5,  two  hours  after  5  grs.  of  sulphate  of  quinia.   Pulse  90. 

Description  Trace  No.  II.  may  be  described  as  follows  :  Percussion 

stroke  perfectly  vertical  and  very  high  (by  exact  measurement  one-third 
higher  than  in  Trace  Xo.  X.,  the  next  highest  observed).  The  angle  be- 
tween the  percussion  stroke  and  the  line  of  descent  of  the  preceding  curve 
is  very  acute.  Entire  absence  of  anacrotismus.  The  systolic  apex  forms 
an  acute  angle,  and  is  followed,  not  by  a  rounded  curve,  but  by  a  hori- 
zontal, even  slightly  concave  line.  The  tidal  wave  is  very  small.  The 
line  of  descent  is  abrupt,  and  the  dicrotic  elevation  very  near  to  its  ter- 
minus. Finally,  the  inspiratory  depression  in  the  ligne  d' 'ensemble  is 
enormous. 

1  The  percussion  stroke  is  shorter  during  inspiration  than  during  expiration.  Since 
at  this  moment  the  cerebral  resistance  is  diminished,  this  shortening  must  be  due,  not 
to  increased  resistance,  but  to  diminished  force  of  the  heart.  This  diminution  is 
caused  by  the  "  negative  pressure"  exercised  on  the  heart  during  the  expansion  of  the 
thorax,  and  thus  is  secured  a  real  intermittence  in  the  blood-pressure  to  which  the 
brain  is  subjected. 


1878.]    J ac obi,  Sphygmographic  Experiments  on  the  Brain.  107 


The  membranes  bulged  more  at  each  cardiac  systole  than  before  the 
administration  of  the  quinia,  but  were  not  tense. 

Interpretation  The  height  and  vertical  direction  of  the  percussion 

stroke  are  not  exclusively  due  to  increased  energy  of  the  cardiac  systole, 
since  when  this  is  obtained  by  brandy  the  percussion  stroke  is  much  lower 
(see  Trace  No.  IV.).  Hence,  in  addition  to  the  effect  on  the  heart,  there 
must  be  diminution  of  the  intra-cranial  resistance.  The  acute  angle  of  the 
systolic  apex  implies  an  instantaneous  momentary  collapse  of  the  cerebral 
bloodvessels  after  their  distension  by  the  percussion  stroke.  From  the 
smallness  of  the  tidal  wave  we  must  conclude  that  little  blood  is  retained 
in  the  arteries  at  any  given  time.  But  the  prolonged  horizontal  line  be- 
tween the  systolic  apex  and  the  summit  of  the  tidal  wave,  implies  a  sus- 
tained tension  of  the  arterial  walls.  The  line  resembles  that  observed  in 
traces  from  atheromatous  arteries.  But  the  abrupt  line  of  descent  indicates 
powerful  elastic  contraction  of  the  arteries,  contrary  to  what  is  seen  in 
atheroma. 

Conclusion. — By  a  tonic  dose  of  quinia,  the  energy  of  the  cardiac  sys- 
tole is  increased ;  the  tonus  and  elasticity  of  the  walls  of  cerebral  blood- 
vessels are  also  increased,  so  that  the  blood  is  forced  rapidly  on  through 
the  capillaries,  thus  diminishing  the  resistance  to  the  cardiac  systole. 
More  blood  is  admitted  to  the  brain,  but  the  intra-cranicd  pressure  is 
lessened. 


Trace  III. 


Two  hours  after  20  grs.  of  quinia.   Pressure  5.   Pulse  96.   Temperature  fallen  one  degree. 
Membranes  depressed. 

Description  of  Trace  III. — Percussion  stroke  vertical,  but  shorter 
than  in  Trace  II.  Systolic  apex  angle  acute,  and  followed  by  descending 
instead  of  horizontal  line.  Tidal  wave  unequally  developed,  in  some  curves 
almost  absent,  in  all  very  small,  and  far  below  the  level  of  systolic  apex. 

Interpretation. — Diminished  intra-cranial  resistance  to  percussion  stroke  ; 
nevertheless,  small  amount  of  blood  thrown  into  brain,  rapid  and  complete 
collapse  of  cerebral  arteries. 

Conclusion  Diminished  energy  of  cardiac  contractions,  unfilled  cere- 
bral arteries,  great  diminution  in  intra-cranial  pressure. 

It  is  important  to  notice  that  the  radial  pulse  taken  at  this  time  exhibited 
a  relatively  much  larger  tidal  wave  and  higher  tension  than  was  shown  by 
these  cerebral  traces.  We  should  infer  therefore  that  the  diminution  of 
intra-cranial  pressure  was  out  of  proportion  to  the  general  diminution  of 
pressure  in  the  arterial  system  connected  with  sedation  of  the  heart. 

Description  of  Trace  /^.—Percussion  stroke  not  quite  vertical,  much 
shorter  than  after  quinia  ;  systolic  apex  forming  a  right,  instead  of  an 


108        J ac obi,  Sphygmographic  Experiments  on  the  Brain. 


acute  angle ;  tidal  wave  greatly  developed  ;  line  of  descent  oblique  and 
gradual ;  angle  between  it  and  the  following  percussion  stroke  rather 
wide ;  dicrotism  scarcely  perceptible ;  inspiratory  depressions  not  very 
marked,  and  much  prolonged,  comprising  four  curves,  while  the  period  of 
expiration  comprises  three. 


Trace  IV. 


Pressure  5.   After  3  drachms  of  brandy.   Pulse  104.    Membranes  tense,  bulging. 


The  membranes  were  tense,  bulging,  and  affected  by  a  peculiar  heaving 
pulsation,  not  seen  in  any  other  case;  the  pulse  was  104. 

Interpretation  Increased  mass  of  blood  in  brain  ;  increased  resistance 

to  percussion  stroke  dependent  on  this,  and  less  than  that  which  would  be 
associated  with  contracted  arteries  ;l  (see  Trace  I.)  slow  collapse  of  arterial 
walls,  notwithstanding  rapid  circulation  ;  increased  duration  of  inspiration  ; 
slow  aspiration  of  blood  from  brain. 

Conclusion  is  mainly  expressed  in  the  interpretation.  The  increased 
force  of  the  heart  is  indicated  by  the  radial  pulse ;  its  effect  on  the  brain 
as  shown  in  the  trace,  is  partially  compensated  by  the  increased  intra- 
cranial resistance.  The  cerebral  bloodvessels  are  dilated,  implying  di- 
minished  tonus  of  their  walls  ;  the  intra-cranial  pressure  increased. 


Trace  Y. 


After  5  gtrs.  tincture  belladonna  ter  in  die  for  four  days,  and  5  gtts.  every  three  hours  on  fifth  day. 
Pulse  10S.    Pupils  moderately  dilated,  membranes  bulging,  not  tense  in  recumbent  position. 


Description  of  Trace  V. — General  resemblance  to  Trace  IV.  under 
brandy.  Percussion  stroke  one-fifth  higher  than  in  Trace  IV. ;  systolic 
apex  a  right  or  slightly  obtuse  angle;  tidal  wave  developed  about  as  much 
as  with  the  brandy ;  line  of  descent  gradual,  without  dicrotism ;  absence  of 
inspiratory  depression  ;  rise  of  entire  ligne  d*  ensemble,  as  if  from  prolonged 
expiratory  effort.  All  the  characteristics  of  the  trace  were  developed  un- 
der a  pressure  of  four  ounces,  as  was  not  the  case  with  brandy;  but  the 
percussion  stroke  was  then  higher  than  is  represented  in  Trace  V.  The 
membranes  did  not  bulge  at  all  when  the  boy  was  vertical. 


1  Hence  the  percussion  stroke,  though  short,  is  not  anacrotic. 


1878.]    J  a  cost,  Sphygmographic  Experiments  on  the  Brain.  109 


Interpretation  and  Conclusions  Mass  of  blood  in  the  brain  increased 

about  the  same  as  after  brandy  ;  but  intra -cranial  pressure  less  (as  shown 
by  condition  of  membranes,  and  response  to  lower  pressure  of  sphygmo- 
graph).    Expiration  prolonged. 

Re  marls  From  the  traces  alone  it  is  rather  difficult  to  understand  why 

the  tension  of  the  membranes  should  have  been  so  great  with  the  brandy, 
and  *so  slight  with  the  belladonna ;  the  rapidity  of  the  circulation  was  al- 
most the  same  in  the  two  cases  (pulse  104  and  108).  The  difference 
probably  depends  on  accelerated  capillary  circulation  in  the  case  of  bella- 
donna, and  retard  of  the  same  after  brandy. 


Trace  VI. 


Before  atropia,  membranes  depressed. 


Trace  VII. 


30  minutes  after,  1  gr.  atropia,  subcutaneously.   Pulse  120. 


Description  Trace  VII.    Half  an  hour  after  g^th  gr.  atropia  shows, 

as  compared  with  Trace  VI.,  taken  just  before;  that  the  percussion  stroke 
is  double  the  height,  and  more  nearly  vertical ;  the  anacrotism  has  disap- 
peared; the  angle  of  the  systolic  apex  rounded,  but  followed  by  descending 
instead  of  ascending  line ;  tidal  wave  much  diminished;  dicrotic  elevation 
increased,  and  nearer  by  one-fifth  to  the  percussion  stroke — that  is,  the 
duration  of  the  ventricular  systole  is  one-fifth  less.  Inspiratory  depression 
remains  the  same,  slightly  marked,  and  comprising  a  single  curve.  The 
membranes  were  raised,  but  neither  tense  nor  bulging.  The  radial  pulse 
had  become  dicrotic. 

Interpretation — Relaxation  of  cerebral  bloodvessels ;  consequent  dimin- 
ished intra-cranial  resistance  to  percussion  stroke;  more  rapid  collapse  of 
arterial  Avails ;  diminution  in  mass  of  blood  retained  in  brain. 

Conclusion  Diminution  of  intra-cranial  pressure,  but  increased 

amount  of  blood  passing  through  brain  in  given  time;  on  account  of  ac- 
celerated cardiac  action  and  diminished  resistance  to  it. 

Description. — The  peculiar  effect  produced  by  the  drug  is  not  percepti- 
ble in  any  individual  trace  alone,  but  in  a  comparison  between  the  traces 
taken  under  moderate  pressure  (four  and  five  ounces,  Trace  IX.),  or 
under  higher  pressure  (six  ounces,  Trace  VIII. ).  In  this  the  ascending 
stroke  is  anacrotic,  in  the  others  not.  The  tidal  wave  is  also  much  less 
developed. 

Interpretation  The  increase  in  pressure  of  the  sphygmograph  lever 

is  transmitted  to  the  cerebral  arteries,  so  as  to  offer  decidedly  increased 


Jacobi,  Sphygmograpliic  Experiments  on  the  Brain.  [July 


resistance  to  the  ventricular  systole,  and  instead  of  developing  fche  percus- 
sion stroke,  breaks  it.  That  such  slight  increase  of  pressure  is  able  to 
cause  anacrotismus,  shows  that  the  force  of  this  systole,  i.  e.,  of  the  heart's 


Trace  VIII. 


Pressure  6. 


Trace  IX. 


2£  hours  after  J  gr.  tartar  emetic.    No  vomiting.    Membranes  apparently  tense,  bulging. 
Pulse  112.    Pressure  5. 

action,  has  been  weakened  relatively;  that  the  intra-cra mat  pressure  is 
not  only  diminished,  but  is  easily  overcome  by  external  pressure;  in  other 
words,  that  the  walls  of  the  arteries  are  relaxed.  This  peculiarity  is  not 
observed  in  any  other  trace,  even  that  of  the  sedative  dose  of  quinia,  but 
is  confined  to  the  nauseating  dose  of  tartar  emetic.  After  vomiting,  the 
intra-cranial  pressure  is  raised,  and  resists  the  higher  pressure  of  the 
sphygmograph. 


Trace  X. 


Pressure  5.    Before  coffee,  pulse  112.   Membranes  tense,  bulging. 


Trace  XI. 


Pressure,  5.    Half  an  hour  after  4  oz.  strong  infusion  coffee.    Membranes  much  depressed. 

Pulse  112. 

Description  (Trace  XI.)  Absence  of  inspiratory  depression,  which 

has  been  marked  in  Trace  X.  Percussion  stroke  shortened  to  one-fifth  the 
height,  oblique,  instead  of  vertical;  higher  under  pressure  6  than  5.  Dimi- 
nution of  tidal  wave.  The  membranes  were  depressed,  which  had  been 
bulging.  The  radial  pulse  remains  the  same  in  rapidity,  and  also  in  the 
form  of  the  sphygmograpliic  trace  (not  here  given). 

Interpretation. — From  this  last  fact  it  is  evident  that  the  percussion 
stroke  has  not  been  shortened  by  weakening  the  force  of  the  cardiac  con- 
traction. The  shortening  must,  therefore,  be  due  to  an  increased  resist- 
ance in  the  brain.    As  there  is  not  an  increased  mass  of  blood  in  the  brain, 


1878.]    Jacobi,  Sphygmographic  Experiments  on  the  Brain.  Ill 


the  resistance  implies  increased  tonicity — increased  contraction  of  blood- 
vessels. This  tonicity  is  only  overcome  by  greater  external  pressure ;  hence 
percussion  stroke  is  more  developed  under  pressure  6  than  5  (reverse  of 
tartar  emetic). 

Conclusion. —  The  amount  of  blood  circulating  in  the  brain  is  smaller, 
but  it  is  brought  to  nerve  tissues  under  increased  pressure  ;  hence  assimi- 
lation of  nutritive  material  should  be  increased  in  rapidity,  if  lessened  in 
quantity.  The  intra -cranial  pressure,  on  the  whole,  i.  e.,  against  the  mem- 
branes, is  diminished. 


Trace  XII. 


Pressure  4.    Three  hours  after  twenty  grains  of  bromide  of  potassium. 


Trace  XIII. 


Pressure  5.    Pulse  76  ;  membranes  depressed  below  cranial  level. 

Description. — Great  development  of  tidal  wave,  perceptible  under  all 
pressures.  At  pressure  4,  percussion  stroke  so  oblique  as  to  merge  into 
tidal  wave.  Trace  .resembles  that  from  an  aneurismal  tumour.1  Under 
pressure  5,  percussion  stroke  sometimes  vertical,  sometimes  oblique.  Line 
of  descent  prolonged  and  gradual,  without  trace  of  direction. 

Interpretation — The  trace  must  be  considered  in  connection  with  the 
facts,  that  the  membranes  had  become  depressed,  and  the  tidal  wave  of 
the  radial  pulse  extremely  small  under  the  influence  of  the  bromide.  It 
is  to  be  inferred,  therefore,  that  the  large  tidal  wave  in  the  cerebral  trace 
does  not  depend  upon  an  unusual  amount  of  blood  thrown  into,  or  con- 
tained in.  the  brain,  but  upon  unusual  obstacles  to  its  passage  out  of  the 
brain.  This  implies  a  contraction  of  the  smallest  bloodvessels  and  capil- 
laries, the  larger  remaining  the  same,  and  thus  offering  no  other  obstacle 
to  the  ventricular  systole  than  the  prolonged  retention  of  blood  in  them  ; 
the  latter  causing  increased  lateral  pressure,  identical  with  that  of  a 
large  tided  wave. 

Conclusion — TJte  intra-cranial pressure,  on  the  whole,  i.  e.,  against  the 
membranes,  is  diminished ;  but  the  brain  tissue  is  subjected  to  a  mechanical 
pressure  from  fulness  of  the  vascular  canals  before  the  point  ivhere  they 
begin  to  be  nutritive,  and  because  of  relative  exclusion  of  the  blood  from 
the  latter. 

Remarks — The  descriptions  of  the  traces  of  coffee  and  bromide  read 
a  good  deal  alike,  except  in  regard  to  the  tidal  wave ;  but  the  traces  are 


1  See  trace  given  by  Mahomed,  Medical  Times  and  Gazette,  1873,  p.  222. 


112 


Bull,  Pathology  of  Orbital  Cellulitis. 


[July 


conspicuously  different.  The  difference  probably  depends  on  the  different 
rate  of  the  circulation,  on  the  different  direct  action  of  the  drugs  on  the 
nerve  tissues,  and  on  the  exercise  of  lateral  pressure  in  the  nutritive 
bloodvessels  in  the  case  of  the  coffee  ;  in  the  canals  leading  to  them,  in  the 
case  of  the  bromide.  In  the  case  of  the  brandy  an  increased  tidal  wave 
was  interpreted  as  evidence  of  dilatation  of  cerebral  bloodvessels,  because 
of  the  visible  increase  in  the  tension  of  the  cerebral  membranes  and  the 
state  of  the  radial  pulse  which  coexisted. 

The  characteristic  trace  of  the  bromide  was  not  developed  until  three 
hours  after  its  administration.  It  was  most  characteristic  at  a  low  pres- 
sure (4).  It  is  not  believed  that  the  whole,  or  even  the  greater  part  of 
the  physiological  action  of  bromide  of  potassium  can  be  explained  by  this 
effect  upon  the  cerebral  bloodvessels. 

To  what  extent  the  conclusions,  drawn  from  these  observations,  are  in 
accordance  with  existing  theories,  may  be  considered  on  another  occasion. 
On  this,  we  content  ourselves  with  registering  the  facts. 


Article  XI. 

A  Contribution  to  the  Pathology  of  Orbital  Cellulitis.  By 
Charles  Stedman  Bull,  A.M.,  M.D.,  Surgeon  to  the  New  York  Eye  In- 
firmary and  to  Charity  Hospital. 

Though  cases  of  inflammation  of  the  tissues  of  the  orbit  are  from  time 
to  time  published,  and  though  orbital  cellulitis  cannot  be  justly  considered 
a  rare  disease,  yet  the  state  of  our  knowledge  upon  its  pathology  and 
etiology  is  still  unsatisfactory.  In  not  a  few  cases  the  obscurity  which 
rests  upon  its  origin  needs  clearing  up,  and  the  course  sometimes  pursued 
by  the  inflammatory  process  requires  explanation.  Yet  when  we  come 
to  consider  the  orbit  more  closely,  it  would  seem  as  if  no  mystery  should 
be  attached  to  the  subject.  The  large  amount  of  adipose  and  connective 
tissue,  and  the  numerous  vessels  and  nerves,  would  naturally  form  a  region 
in  which  an  inflammatory  process  would  easily  rise  and  rapidly  spread. 
In  the  literature  of  the  subject  the  most  various  causes  are  enumerated 
their  number  being  almost  legion.  Among  the  most  important  are  acute 
infectious  diseases,  as  typhus,  scarlatina,  etc.;  facial  erysipelas,  foreign 
bodies  in  the  orbit,  wounds  of  various  kinds ;  and  among  these  may  be 
included  operations  upon  the  eyeball,  or  in  its  immediate  vicinity.  Thus 
severe  orbital  cellulitis  has  been  known  to  follow  an  operation  for  squint, 
done  in  the  correct  manner  and  by  a  very  skilled  hand.  Sonnenburg  re- 
ports such  a  case,  in  which,  however,  the  inflammation  ended  in  resolu- 
tion and  did  not  go  on  to  suppuration.  Laqueur  has  observed  cellulitis  to 
follow  enucleation  of  the  eyeball. 


1878.] 


Bull,  Pathology  of  Orbital  Cellulitis. 


113 


But  sometimes  cases  occur  without  any  known  cause  for  the  inflamma- 
tion. Sonnenburg  {Deutsche  Zeitsch.  fiir  Chirurgie,  1877)  reports  two 
such  cases,  in  both  of  which  the  eyes  were  completely  destroyed.  He 
seems,  however,  inclined  to  compare  them  with  similar  phlegmonous  pro- 
cesses occurring  in  other  parts  of  the  body,  and  due  to  some  infection  or 
blood  poisoning.  The  symptoms  of  orbital  cellulitis  are  always  charac- 
teristic, and  witli  ordinary  care  no  difficulty  in  diagnosis  exists.  The  dis- 
ease often  begins  with  a  chill,  followed  by  high  fever,  or  there  may  be  no 
chill,  but  simply  a  general  feeling  of  malaise.  An  intense,  deep-seated 
pain  is  then  felt  in  the  orbit,  injection  and  chemosis  of  the  ocular  conjunc- 
tiva make  their  appearance,  the  eyelids  begin  to  swell  and  grow  red ;  and 
the  same  process  going  on  in  the  orbit  behind  the  eyeball,  the  latter  be- 
gins to  protrude,  and  wre  have  exophthalmus.  As  the  inflammation  be- 
comes more  intense,  and  the  prominence  of  the  eyeball  more  marked,  its 
movements  become  more  or  less  completely  impeded,  and  finally  the  eye 
is  absolutely  motionless.  Before  this,  however,  the  eye  itself  is  involved 
in  the  destructive  inflammation.  Owing  to  the  great  infiltration  and 
chemosis  of  the  ocular  conjunctiva,  the  cornea  is  surrounded  by  a  tense 
wall  in  which  it  lies  sunken,  its  nutrition  is  interfered  with  or  entirely 
interrupted,  it  rapidly  becomes  opaque,  and  soon  sloughs  away  entirely  or 
in  part.  From  the  cornea  the  destructive  process  extends  to  the  deeper 
tissues  of  the  eyeball,  and  it  is  not  uncommon  to  have  a  panophthalmitis 
as  the  result.  If  the  cornea  remains  transparent,  yet  is  the  danger  to  the 
eye  not  passed  by for  the  optic  nerve  becomes  constricted  behind  the 
eyeball  by  the  mass  of  exudation  thrown  out  into  the  orbital  tissue,  and 
the  result  is  again  disastrous  to  vision.  Or  again,  if  neither  of  these  re- 
sults occur,  the  eyeball  still  runs  a  third  danger  from  suppurative  panoph- 
thalmitis, starting  up  directly  in  the  eye  from  interruption  to  its  blood- 
supply  by  the  mass  of  exudative  material  surrounding  it  in  the  orbit. 

As  before  remarked,  Sonnenburg  advances  the  view  that  real  inflam- 
mation of  the  orbital  adipose  tissue  is  connected  with  inflammatory  pro- 
cesses in  the  face,  pharynx,  and  posterior  nares,  just  as  phlegmonous  pro- 
cesses in  the  neck  are  thus  connected.  Without  denying  the  justice  of 
these  views,  I  have  never  seen  a  case  in  which  it  was  necessary  to  go  so 
far  for  a  cause.  In  the  cases  to  be  detailed,  there  was  no  blood  poisoning 
of  any  kind,  and  yet  in  all  of  them  the  causation  was  somewhat  obscure. 

Though  occasionally  death  supervenes  in  these  cases  from  an  extension 
of  the  suppurative  process  backward  to  the  meninges  of  the  brain,  yet  this 
\  is  such  an  uncommon  occurrence,  that  the  post-mortem  appearances  of  an 
orbital  cellulitis  are  but  little  known.  Panas,  however,  reports  such  a 
case  in  the  Recueil  d'  Ophthalmologie  for  January,  1874,  and  gives  the 
results  of  the  autopsy. 

The  case  was  a  young  man  in  whom  the  orbital  tissue  became  in- 
flamed as  a  consequence  of  a  spontaneous  attack  of  facial  erysipelas. 
No.  CLI  July  1878.  8 


114  Bull,  Pathology  of  Orbital  Cellulitis.  [July 


Panas  saw  the  case  nine  days  after  the  erysipelas  made  its  appearance, 
and  found  at  that  time  white  degeneration  of  the  optic  papilla,  supposably 
from  compression  of  the  nerve.  The  case  lasted  from  May  15th  to 
November  1st,  when  death  occurred  from  meningitis.  At  the  autopsy 
there  was  no  apparent  external  lesion  of  the  eyeball.  That  portion  of 
the  cellular  tissue  known  as  the  capsule  of  Tenon  was  perfectly  normal, 
and  this  must  be  regarded  as  a  most  singular  fact,  in  view  of  the  inti- 
mate connection  existing  between  this  membrane  and  the  contents  of 
the  orbit,  and  the  very  severe  inflammation  which  had  existed  in  the 
latter.  On  the  contrary,  all  the  other  contents  of  the  orbit,'  situated  be- 
hind the  fibrous  capsule  of  the  eyeball,  in  what  Panas  calls  the  summit  or 
apex  of  the  orbit,  were  discoloured,  lardaceous,  and  all  bound  down  into 
one  confused  mass,  including  the  optic  nerve,  which  had  to  be  carefully 
dissected  out.  Another  interesting  point  in  the  autopsy  was,  that  the 
ophthalmic  artery  and  vein,  though  very  much  reduced  in  calibre,  were 
still  permeable.  In  this  case  only  the  posterior  part  of  the  optic  nerve  in 
the  orbit  was  directly  connected  with  the  orbital  lesion.  Furthermore 
the  inflammatory  process  had  extended  to  the  brain  through  the  sphe- 
noidal fissure,  and  not  by  means  of  the  ophthalmic  vein  and  cavernous 
sinus,  and  this  without  involving  the  capsule  of  Tenon.  The  atrophic 
discolouration  of  the  papilla  might  have  been  supposed  to  be  due  to  com- 
pression, but  a  careful  examination  of  the  optic  nerve  showed  it  to  be  the 
seat  of  a  neuritis  from  the  optic  foramen  to  the  eyeball.  Sections  made 
at  different  points  in  its  course,  perpendicular  to  its  axis,  showed  that  the 
place  of  the  nerve  fibres  was  taken  by  a  grayish,  translucent,  homogeneous 
tissue,  intimately  connected  with  the  fibrous  sheath  of  the  nerve,  and  en- 
tirely formed  of  proliferating  connective  tissue.  There  was  no  trace  of 
the  central  retinal  artery.  In  the  vicinity  of  the  lamina  cribrosa  there 
was  not  a  trace  of  nerve  fibres.  Hence  the  atrophy  in  this  case  was  due 
to  a  proliferating  neuritis,  though  the  compression  in  the  orbit  may  have 
had  something  to  do  with  the  origin  of  the  neuritis. 

The  following  five  cases  are  reported  in  full,  because  of  their  unusual 
origin,  the  causation  in  each  being  different,  and  more  or  less  directly 
traceable,  except  in  one  instance.  Some  interesting  points  in  pathology 
are  also  shown,  and  may  therefore  be  a  sufficient  excuse  for  the  detailed 
history  of  the  cases. 

The  first  case  originated  in  an  aggravated  exacerbation  of  trachoma 
and  pannus,  ended  in  total  destruction  of  the  eyeball,  and  the  stump  and 
mass  of  infiltrated  orbital  tissue  were  subsequently  enucleated,  and  sub- 
mitted to  a  microscopic  examination. 

The  second  case  originated  in  a  lacerated  wound  of  the  eyelids,  the  sup- 
purative process  extending  from  the  lids  directly  into  the  orbital  tissue, 
and  also  ending  in  destruction  of  the  eye. 

The  third  case  started  from  a  large  perforating  ulcer  of  the  cornea,  with 
extensive  prolapse  of  the  iris,  and  ended  in  panophthalmitis,  with  perfora- 
tion of  the  sclera. 

The  fourth  case  was  spontaneous,  and  no  cause,  except  exposure  to  cold 
and  wet,  could  be  discovered.  This  also  ended  in  total  disorganization  of 
the  eye. 


1878.] 


Bull,  Pathology  of  Orbital  Cellulitis. 


115 


The  fifth  case  was  the  most  singular  of  all  in  its  origin,  occurring  on 
the  second  day  after  an  iridectomy  for  glaucoma,  and  starting  from  the 
wound.  The  inflammation  was  accompanied  by  grave  head  symptoms, 
and  ended  in  panophthalmitis. 

In  all  the  cases  the  eye  was  destroyed,  in  four  of  them  the  disintegra- 
tion beginning  in  the  cornea.  No  treatment  seems  to  be  of  any  avail 
either  in  preventing  suppuration  of  the  cornea,  or  in  staying  it  when  once 
it  has  begun.  In  three  of  the  cases  the  orbital  cellulitis  did  not  result  in 
the  formation  of  an  abscess,  but,  after  a  varying  length  of  time,  resolution 
set  in,  and  the  symptoms  then  slowly  subsided,  without  the  appearance  of 
any  purulent  discharge.  According  to  the  text-books  this  must  be  re- 
garded as  an  unusual  occurrence. 

Case  I.    Orbital  Cellulitis  following  Granular  Lids  and  Pannus  

Mary  A.  F.,  aet.  40.  This  patient  had  suffered  from  chronic  trachoma 
and  pannus  for  many  years,  but  had  never  had  any  systematic  treatment. 
She  was  an  inmate  of  Charity  Hospital  in  the  summer  of  1876,  and  while 
there  contracted  acute  blenorrhcea  of  the  eyelids,  which  was  engrafted 
upon  the  chronic  trachoma.  The  attack  was  a  severe  one  in  both  eyes, 
but  the  inoculation  proved  to  have  been  a  most  successful  treatment  for 
the  pannus ;  for  the  cornese,  which  had  been  very  vascular  and  fleshy, 
began  to  clear  up,  and  in  about  four  months  she  was  discharged  with  one 
perfectly  clear  cornea,  and  very  useful  vision  in  the  other  eye.  In  the 
latter  part  of  December,  1876,  both  eyes  again  became  irritable,  and  on 
admission  to  the  hospital  it  was  found  that  the  trachoma  had  started  up 
again.  On  Jan.  3,  1877,  while  the  case  was  progressing  favourably,  the 
patient  had  a  severe  chill,  which  lasted  about  thirty  minutes,  and  was 
rapidly  followed  by  three  more.  Then  began  a  deep-seated,  throbbing 
pain  in  the  right  orbit;  the  eyelids  became  rapidly  injected  and  swollen, 
and  a  dark-coloured,  congested  appearance  of  the  conjunctiva  appeared  at 
the  line  of  insertion  of  the  external  rectus  muscle.  Severe  pain  was  then 
complained  of  in  the  right  temple,  the  ocular  conjunctiva  became  very 
cedematous,  the  oedema  spreading  from  the  point  of  deep  injection  over 
the  external  rectus,  at  first  backwards  in  the  course  of  the  muscle,  just  as 
the  injection  had  done,  but  rapidly  surrounding  the  entire  cornea.  The 
eye  soon  began  to  protrude ;  the  eyelids  became  very  tense,  hot,  shining, 
and  almost  purple  in  colour ;  and  this  engorgement  of  the  vessels  extended 
from  the  inner  canthus  over  upon  the  nose,  down  from  the  lower  lid  upon 
the  cheek,  and  outwards  from  the  external  canthus  upon  the  temple  and 
side  of  the  jaw.  There  was  no  extension,  however,  upwards  upon  the 
forehead,  which  I  regarded  as  singular.  The  face  was  not  erysipelatous, 
but  the  vascular  injection  was  certainly  remarkable.  On  the  fourth  day 
the  cornea,  which  had  been  tolerably  clear,  was  sunken  deep  within  the 
oedematous  conjunctiva,  became  rapidly  infiltrated,  and  was  soon  little 
more  than  a  mass  of  pus.  The  lower  lid  by  this  time  was  completely 
everted  by  the  swollen  conjunctiva  and  infiltrated  subconjunctival  tissue.. 
At  this  time  the  patient  began  to  complain  of  a  very  severe  pain  along 
the  superior  orbital  margin,  which,  on  the  slightest  pressure,  became  ago- 
nizing. It  seemed  to  be  of  an  entirely  different  character  from  the  deep- 
seated  orbital  pain,  and  did  not  extend  upwards  upon  the  forehead,  or 
seem  to  involve  the  supraorbital  nerve.    When  the  symptoms  of  orbital 


116 


Bull,  Pathology  of  Orbital  Cellulitis. 


[July 


trouble  first  appeared,  a  large  dose  (grs.  xv.)  of  the  sulphate  of  quinia 
was  administered,  and  cold  applications  ordered  to  be  used  constantly. 
As  soon  as  the  tendency  to  the  formation  of  pus  became  marked,  these 
were  stopped,  and  hot  applications  were  employed  assiduously,  with  opium 
to  allay  the  pain.  As  soon  as  the  exophthalmos  appeared  free  incisions 
were  made  in  the  orbital  tissue  with  a  sharp-pointed,  straight  bistoury,  in 
various  directions.  In  several  instances  the  knife  was  pushed  backward 
till  it  reached  the  rear  wall  of  the  orbit ;  but  on  no  occasion  was  pus 
reached.  Under  the  influence  of  heat,  the  discharge  became  profuse,  but 
there  was  very  little  pus,  and  at  no  time  was  the  discharge  anything  more 
than  a  bloody  mucus,  or  thin  muco-pus.  On  the  twelfth  day  the  conjunctiva 
over  the  temporal  side  of  the  eyeball,  ulcerated  about  five  lines  from  the 
corneal  margin,  and  the  ulcer  soon  reached  the  size  of  a  three-cent  silver 
piece.  A  probe  could  be  passed  backward  about  half  an  inch,  but  there 
was  no  perforation  of  the  eyeball  until  five  days  later,  when  the  sclera 
ulcerated,  and  a  bead  of  purulent  vitreous  made  its  appearance.  From 
this  time  the  symptoms  slowly  subsided,  the  lids  became  less  tense  and 
red,  the  exophthalmus  receded,  the  eyeball  slowly  contracted  under  the 
influence  of  a  subsiding  panophthalmitis,  and  the  pain  ceased  as  suddenly 
as  it  began.  On  July  20,  1877,  the  stump  of  the  eye  was  enucleated,  and 
the  patient  has  since  worn  an  artificial  eye.  The  abortive  treatment  by 
large  doses  of  quinia,  repeated  leeching,  and  the  constant  application  of 
cold,  here  failed  utterly.  There  were  some  unusual  features  in  the  course 
taken  by  the  disease  in  this  case.  The  interference  in  the  return  circula- 
tion of  the  nose  and  cheek  on  the  affected  side  was  very  marked,  and  is  a 
phenomenon  which  I  have  not  seen  noted  in  the  text-books.  The  failure 
to  reach  any  purulent  deposit  by  the  knife,  and  the  very  small  amount  of 
pus  discharged,  seemed  strange,  but  I  have  since  met  with  the  same  thing 
several  times.  The  occurrence  of  the  peculiar  pain  along  the  orbital 
margin  pointing  to  a  marginal  periostitis,  and  its  subsidence  without  lead- 
ing to  serious  bone  trouble,  is  not  common. 

At  the  time  of  the  enucleation,  six  months  after  the  occurrence  of  the 
cellulitis,  an  attempt  was  made  to  remove  a  piece  of  the  optic  nerve  in 
addition  to  the  stump,  but  it  was  found  so  adherent  to  the  orbital  tissue 
that  it  could  not  be  pulled  forward.  The  remains  of  the  orbital  tis.-ue, 
matted  together  by  the  products  of  inflammation,  were  then  loosened  from 
the  orbital  wall  and  excised,  together  with  a  piece  of  the  optic  nerve 
nearly  half  an  inch  long,  for  purposes  of  examination.  This  tissue  was  a 
dense,  compact  mass  closely  surrounding  and  connected  with  the  sheath  of 
the  optic  nerve,  and,  after  being  hardened,  was  examined  microscopically. 
The  sections  showed  a  compact,  dense  mass  of  connective-tissue  fibres, 
with  numerous  fusiform  cells,  and  some  round  cells,  granular  and  nu- 
cleated ;  scarcely  a  trace  of  the  normal  adipose  tissue  of  the  orbit,  and  a  very 
marked  hyperplasia  of  the  optic  nerve-sheath.  There  was  no  noticeable 
difference  between  the  sheath  and  surrounding  tissue.  There  wa-s  a  well- 
marked  thickening  of  the  fibrillary  trabecular  of  the  optic  nerve,  showing 
that  there  had  been  an  extensive  neuritis.  Towards  the  centre  of  the 
nerve  there  were  still  some  nerve  fibres  intact,  but  the  mass  of  the  nerve 
fibres  had  disappeared,  and  their  place  occupied  by  organized  inflamma- 
tory exudation,  fibres,  and  cells.  This  hyperplasia  of  the  connective- 
tissue  framework  of  the  nerve  extended  nearly  to  the  lamina  cribrosa. 
The  central  vessels  of  the  nerve  were  obliterated  except  near  the  eyeball, 
where  there  were  still  some  blood  corpuscles  within  the  very  reduced 
calibre  of  the  artery. 


1878.] 


Bull,  Pathology  of  Orbital  Cellulitis. 


117 


There  was  no  apparent  thickening  of  the  orbital  margin,  where  one 
might  have  expected  to  find  traces  of  the  attack  of  periostitis,  which  had 
occurred  in  the  course  of  the  cellulitis.  The  stump  of  the  eye  showed  the 
usual  signs  of  a  preceding  panophthalmitis.  The  capsule  of  Tenon  was 
thickened  and  firmly  adherent  to  the  sclera,  but  beyond  this  there  were  no 
unusual  features  shown  on  microscopical  examination. 

There  was  no  trace  of  the  ciliary  nerves  in  the  mass  removed  from  the 
orbit,  though  a  very  careful  search  was  made  for  them.  In  the  stump  of 
the  eye  there  were  traces  of  nerve  fibres  in  places,  but  they  could  not  be 
followed  through  the  thickened  sclera,  and  were  hence  probably  entirely 
atrophied. 

Case  II.  Orbital  Cellulitis  following  Suppuration  of  the  Eyelids  from 

a  Lacerated  Wound  Lizzie  M.,  cet.  26,  seamstress,  admitted  to  Charity 

Hospital  in  the  summer  of  1877.  Patient  has  led  an  irregular  dissipated 
life  for  several  years.  In  the  latter  part  of  May,  she  received  several  blows 
in  the  face  in  a  drunken  brawl,  one  of  which  produced  a  severe  laceration 
of  both  lids  of  the  left  eye.  She  was  treated  outside  and  the  wounds 
sewed  up,  but  the  eyelids  subsequently  became  very  tense  and  red,  and 
after  about  two  weeks  she  entered  the  hospital.  The  left  upper  and  lower 
lids  were  found  very  much  swollen  and  reddened,  boggy,  and  evidently 
containing  pus.  There  was  a  long  ragged  wound  through  the  upper  lid, 
just  to  the  inside  of  its  centre,  and  extending  from  the  palpebral  margin 
upwards  and  inwards  nearly  to  the  orbital  margin.  In  the  lower  lid  the 
laceration  extended  through  the  entire  lid  and  down  upon  the  cheek  in  a 
direction  downwards  and  outwards,  with  its  upper  end  reaching  the  carun- 
cle and  dividing  the  lower  lachrymal  canal.  There  was  a  large  extrava- 
sation of  blood  beneath  the  skin  of  the  cheek,  temple,  and  forehead.  The 
cornea  and  aqueous  were  clear,  as  were  the  other  media,  and  the  eyeball 
was  apparently  uninjured,  but  there  was  a  suspicious  chemosis  of  the 
ocular  conjunctiva  surrounding  the  lower  margin  of  the  cornea,  and  a 
slight  degree  of  exophthalmus.  Both  lids  were  freely  incised  horizontally, 
and  considerable  offensively  smelling  pus  evacuated.  The  wounds  were 
carefully  probed,  but  no  foreign  body  or  dead  bone  could  be  found.  They 
were  then  syringed  with  a  solution  of  carbolic  acid,  and  plain  cold  water 
dressings  employed.  Six  leeches  were  applied  to  the  left  temple,  and  a  large 
dose  of  quin.  sulph.  administered.  The  next  day  the  lids  were  again  very 
much  swollen,  the  discharge  was  but  slight,  and  the  conjunctival  chemosis 
had  extended  round  nearly  the  entire  cornea.  The  leeching  was  repeated 
and  cold  constantly  applied,  but  the  signs  of  orbital  trouble  became  steadily 
more  marked.  In  the  course  of  the  next  twrenty-four  hours  the  eyeball 
became  very  prominent,  and  at  one  time  the  increase  was  so  sudden  as  to 
cause  a  suspicion  of  a  retro-bulbar  orbital  hemorrhage.  A  long  straight 
bistoury  was  plunged  into  the  orbit  for  the  distance  of  an  inch  in  several 
directions,  but  no  pus,  and  only  slight  bleeding  followed  the  wounds. 
Hot  applications  were  then  ordered  constantly,  and  as  the  patient's  gene- 
ral condition  was  very  unsatisfactory,  tonic  doses  of  iron  and  quinia,  and 
four  ounces  of  whiskey  were  given  daily.  In  spite  of  the  treatment,  and 
frequent  incisions  into  the  orbit,  scarcely  any  pus  made  its  appearance. 
The  lids  remained  as  swollen,  hard,  and  red  as  at  first,  the  exopthalmus, 
which  was  now  very  marked,  remained  unchanged  for  nearly  ten  days, 
and  the  cornea,  at  first  transparent  in  spite  of  the  annular  chemosis  of  the 
conjunctiva,  now  became  slowly  infiltrated  and  opaque.  At  this  period 
there  was  scarcely  any  pain,  except  on  pressure,  and  the  only  symptom 


118 


Bull,  Pathology  of  Orbital  Cellulitis. 


[July 


pointing  to  any  intracranial  complication,  was  a  tendency  to  somnolence. 
Towards  the  end  of  the  third  week  resolution  began,  and  all  the  symptomi 
slowly  subsided.  The  cornea  sloughed,  and  there  was  some  slight  puru- 
lent discharge  from  the  lacerations  in  the  lids,  but  from  first  to  last  there 
was  no  discharge  of  pus  from  the  orbit,  and  hence  no  orbital  abscess.  At- 
tn e  end  of  the  sixth  week  all  swelling  had  subsided,  shrinking  of  the  eye- 
ball was  steadily  going  on,  and  an  attempt  was  made  to  freshen  and  unite 
the  wounds  in  the  lids.  This  succeeded,  and  the  wounds  healed  well, 
though  slowly.  The  wound  through  the  lower  lid  involved  the  canaliculus, 
and  the  distal  end  of  this  would  eventually  be  obliterated,  but  the  end 
next  the  lachrymal  sac  was  slit  up,  and  a  style  introduced  for  three  or  four 
days  to  keep  it  from  closing.  There  was  some  little  ectropium  of  the 
lower  lid,  or  rather  a  falling  away  from  the  eyeball,  but  not  enough  to 
occasion  much  deformity. 

The  points  of  interest  in  this  case  are  the  cause  of  the  orbital  inflamma- 
tion, the  long  continuance  of  the  latter,  and  its  final  resolution  without 
leading  to  the  formation  of  abscess. 

The  inflammatory  process  probably  extended  from  the  laceration  in  the 
lower  lid.  The  wound  here  at  its  upper  end  opened  into  the  orbit,  for  it 
divided  the  lower  canaliculus  and  involved  the  caruncle.  Hence  there 
was  a  possibility  for  the  inflammation  to  extend  by  direct  continuity  from 
the  suppurating  upper  end  of  the  wound  to  the  loose  cellular  tissue  of  the 
orbit.  The  first  appearance  of  the  conjunctival  chemosis  at  the  lower 
margin  of  the  cornea  would  seem  to  favour  this  view. 

In  view  of  the  bad  condition  of  the  patient  and  her  dissipated  habits,  it 
is  strange  that  the  destructive  process  in  the  eyeball  marched  so  slowly. 
The  cornea  remained  clear  for  some  days  in  spite  of  the  marked  conjunc- 
tival oedema,  and  after  the  infiltration  made  its  appearance,  its  progress  to 
complete  suppuration  was  very  slow.  Then  again  the  extreme  violence 
of  the  symptoms  in  a  broken-down  patient  would  ordinarily  soon  lead  to 
suppuration,  especially  where  hot  applications  were  used.  But  here  there 
was  no  suppuration  from  the  inflamed  orbital  tissue,  and  after  three  weeks 
of  violent  inflammatory  action  resolution  set  in,  though  not  until  the  eye- 
ball was  destroyed. 

In  this  case  the  inflammation  was  from  the  first  an  orbital  cellulitis,  and 
did  not,  as  in  two  of  the  cases,  begin  as  a  more  or  less  circumscribed  in- 
flammation of  the  fibrous  capsule  of  the  globe. 

Case  III.  Orbital  Cellulitis  following  a  large  Perforating  Ulcer  of 
the  Cornea  with  Prolapse  of  the  Iris  Thomas  L.,  ret.  45,  hostler,  admit- 
ted to  Charity  Hospital  January  19th,  1878.  Patient  has  been  a  hard 
drinker  all  his  life,  but  has  had  no  venereal  disease.  One  month  before 
admission  his  left  eye  became  inflamed  and  very  painful.  He  underwent 
a  course  of  treatment  at  one  of  the  charitable  institutions  of  the  city,  and 
an  operation  was  done  for  artificial  pupil.  The  eye  steadily  grew 
worse,  and  he  came  into  the  hospital.  Is  subject  to  attacks  of  acute 
rheumatism.  On  examination  there  was  found  a  very  large  central  perfo- 
ration, occupying  about  two-thirds  of  the  entire  left  cornea,  with  a  large 


1878.] 


Bull,  Pathology  of  Orbital  Cellulitis. 


119 


prolapse  of  the  iris,  which  was  covered  by  a  mass  of  exudation.  The 
rest  of  the  cornea  was  infiltrated;  there  was  deep  ciliary  injection, 
exquisite  tenderness  on  pressure,  and  marked  diminution  of  tension. 
V.  perception  of  light.  The  other  eye  was  normal.  Atropia  (4-grain  so- 
lution) was  instilled  every  half  hour,  and  cold  applied  every  two  hours  for 
fifteen  minutes  until  the  next  day.  The  extreme  tenderness  having  then 
somewhat  subsided,  the  large  prolapse  was  excised,  and  a  bandage  was 
then  applied.  During  the  night  the  pain  returned,  and  the  bandage  had 
to  be  removed.  The  case  progressed  slowly  but  favourably  for  eight  days, 
when  the  conjunctiva  round  the  outer  margin  of  the  cornea  suddenly  be- 
came chemotic,  and  the  ciliary  margins  of  both  lids  became  oedematous. 
The  pain,  which  had  been  slight,  now  returned,  and  was  at  first  located 
along  the  upper  orbital  margin,  but  soon  changed  in  character,  became  a 
throbbing  pain,  and  was  referred  by  the  patient  to  the  bottom  of  the  orbit. 
The  chemosis  of  the  conjunctiva  soon  spread  entirely  round  the  cornea, 
but  was  most  marked  on  the  temporal  side.  The  lids  became  enormously, 
swollen,  and  the  swelling  extended  for  some  little  distance  outward  upon 
the  temple.  The  exophthalmus  was  at  no  time  very  marked,  and,  in  spite 
of  the  chemosis  of  the  conjunctiva,  there  was  no  further  extension  of  the 
corneal  infiltration.  The  eyeball,  however,  became  very  hard,  and  was 
absolutely  immovable.  In  this  case  the  orbital  inflammation  did  not 
manifest  its  onset  by  a  chill,  but  was  very  sudden  in  its  appearance,  and 
made  rapid  progress.  Repeated  leeching,  early  and  repeated  deep  inci- 
sions into  the  orbit,  and  the  constant  application  of  heat  failed  to  stay  its 
destructive  march.  An  abscess  formed  above  and  to  the  outside  of  the 
eyeball,  and  was  opened  by  the  knife,  and  a  small  amount  of  pus  dis- 
charged, with  considerable  relief  to  the  patient.  But  the  suppurative 
process  went  on,  burrowed  beneath  the  capsule  of  Tenon  forward,  and 
pointed  just  over  the  equator  of  the  eyeball,  between  the  superior  and  exter- 
nal recti  muscles.  This  was  also  opened,  and  a  probe,  being  introduced, 
passed  through  a  hole  in  the  sclera  into  the  cavity  of  the  eye.  The  pro- 
cess of  recession  and  healing  in  this  case  was  slow.  Pus  continued  to  be 
discharged  from  the  two  openings  in  moderate  quantity  for  about  four 
weeks.  On  April  3d  all  suppuration  had  ceased,  and  the  eye  was  reduced 
to  a  small,  irregularly-quadrilateral  stump,  with  a  large  granulation  over 
the  seat  of  the  second  abscess.  No  sympathetic  trouble  in  the  other  eye 
at  any  time  during  the  course  of  the  inflammation.  The  stump,  however, 
is  exquisitely  sensitive,  and  at  times  the  patient  complains  of  a  sharp, 
severe  pain,  which  seems  to  run  back  "  into  his  head,"  as  he  expresses  it, 
so  that  it  cannot  be  yet  said  that  the  danger  of  sympathetic  trouble  has 
entirely  subsided. 

In  this  case  the  original  trouble  was  no  doubt  an  "ulcus  corneas  ser- 
pens," which  had  gone  on  to  perforation,  and  prolapse  of  a  large  segment 
of  iris.  How  the  orbital  inflammation  originated  is  a  difficult  question  to 
answer.  It  is  of  course  possible  that  a  draught  of  cold  air  blowing  over 
the  patient  in  bed,  or  a  sudden  fall  of  temperature  may  have  been  the  ex- 
citing cause,  but  of  this  he  had  no  recollection.  Any  direct  connection, 
as  of  cause  and  effect,  between  the  ulcerative  process  in  the  cornea  and 
the  orbital  inflammation  cannot  be  traced,  especially  as  we  have  merely 
clinical  observations  to  go  upon.  Such  a  theory  would  need  the  most 
rigid  microscopic  examination  as  a  basis. 


120 


Bull,  Pathology  of  Orbital  Cellulitis. 


[July 


Another  point  to  be  noted  in  this  case,  and  which  I  have  since  seen  in 
other  cases,  was  the  change  in  location  and  character  of  the  pain,  from  a 
sharp,  shooting  pain  along  the  orbital  margin  to  a  dull,  throbbing  pain  in 
the  orbit. 

The  former  did  not  last  long  enough  to  point  to  a  periostitis,  which, 
moreover,  is  not  a  common  complication  of  orbital  cellulitis,  in  spite  of 
statements  to  the  contrary  in  the  text-books. 

Another  point  was  the  (edematous  condition  of  the  ciliary  margin  of  the 
lids,  as  the  first  sign  of  the  swelling  of  the  lids  and  among  the  first  symp- 
toms of  orbital  inflammation. 

Case  IV — Patrick  L.,  aet.  40,  labourer;  admitted  to  the  N.  Y.  Eve 
Infirmary,  February  14th,  1878.  The  patient's  left  eye  was  lost  fifteen 
years  ago  by  a  perforating  wound  of  the  cornea,  just  above  the  lower  and 
nasal  margin.  There  is  one  point  of  anterior  synechia,  lenticular  and  cap- 
sular cataract,  the  somewhat  shrunken  lens  being  attached  to  the  iris  at 
the  point,  of  corneal  adhesion,  and  a  somewhat  atrophied  globe.  Good 
perception  of  light.  While  at  work  four  days  before  admission,  the  right 
eye  became  somewhat  tender  and  red,  and  in  the  course  of  the  day  the 
pain  became  so  severe  that  he  was  obliged  to  stop  work.  On  admission 
there  was  nothing  abnormal  to  be  seen,  except  a  slight  degree  of  deep  in- 
jection and  chemosis  of  the  conjunctiva  just  over  the  insertion  of  the  ex- 
ternal rectus  muscle.  The  pupil  reacted,  the  media  were  all  clear,  the 
fundus  healthy,  and  V.  =§§•  The  eye  was.  however,  very  sensitive  to 
pressure  over  the  point  of  injection.  Suspecting  a  possible  deep-seated 
trouble,  two  leeches  were  applied  to  the  temple,  and  cold  applications  were 
ordered  to  be  constantly  applied.  On  the  second  day  the  injection  and 
chemosis  had  spread  somewhat  towards  the  superior  rectus  muscle,  and 
also  backwards,  and  pain  was  still  severe.  Four  leeches  were  again  ap- 
plied, a  laxative  given,  and  the  cold  applications  kept  up.  On  the  next 
visit,  two  days  later,  the  pain  had  diminished  considerably,  and  the  injec- 
tion and  chemosis  had  not  spread.  The  temple  was  again  leeched,  and  the 
cold  still  continued.  Two  days  later  there  was  a  marked  increase  in  the 
symptoms.  The  whole  ocular  conjunctiva  was  injected,  the  deep  episcleral 
injection  had  extended  backward  and  around  the  cornea,  the  conjunctival 
chemosis  reached  from  the  line  of  the  inferior  to  the  line  of  the  superior 
rectus,  and  projected  considerably  above  the  cornea;  and  just  over  the  in- 
sertion of  the  external  rectus  muscle  was  a  distinct,  hard,  and  exquisitely 
sensitive  prominence,  such  as  we  see  in  scleritis  or  gummy  infiltration  of 
the  sclera.  For  the  first  time  suspicions  of  a  venereal  origin  were  excited, 
but  a  careful  examination  elicited  absolutely  no  symptoms.  Nevertheless 
the  patient  was  immediately  put  upon  anti-syphilitic  treatment,  and  in  ad- 
dition atropia  was  instilled  into  the  eye.  At  the  next  visit,  however,  the 
matter  became  a  little  clearer.  The  conjunctival  chemosis  was  more 
marked,  and  extended  around  about  three-fourths  of  the  entire  cornea  ; 
there  was  slight  exophthalmus,  and  along  the  edges  of  the  lids  there  was 
some  cedema  of  the  skin.  From  this  time  on  the  symptoms  of  orbital  cel- 
lulitis became  very  marked  ;  the  lids  rapidly  became  enormously  swollen 
and  deep  red  in  colour,  the  exophthalmus  increased  from  day  to  day.  and 
the  cornea  was  sunk  within  a  wall  of  swollen  conjunctiva  which  overlapped 
it.  The  pain  was  deep-seated  and  throbbing  in  character,  and  the  patient 
complained  greatly  of  a  soreness  of  the  frontal,  parietal,  and  occipital 


1878.] 


Bull,  Pathology  of  Orbital  Cellulitis. 


121 


regions  of  the  scalp  on  that  side,  which  at  times  amounted  to  an  absolute 
pain.  His  scalp  was  so  sore  that  he  could  not  bear  to  have  it  touched. 
The  cornea  soon  became  infiltrated  throughout  its  entire  extent,  and  finally 
sloughed  off  in  shreds.  Early  and  repeated  incisions  never  reached  any 
deposit  of  pus,  and  there  was  no  purulent  discharge  until  the  lids  became 
relaxed,  and  then  the  pus  seemed  to  come  from  the  conjunctiva,  as  in  cases 
of  blenorrhoea.  The  exophthalmos  lasted  for  a  long  time,  and  was  the  last 
symptom  to  yield.  Here  was  another  instance  in  which  there  was  no  dis- 
charge of  pus  from  the  orbit  ,  in  spite  of  constant  hot  applications  and  free 
incisions  into  the  inflamed  tissue. 

This  patient  presented  the  same  early  symptom  of  the  swelling  of  the 
eyelids  in  a  slight  oedema  of  their  ciliary  margin,  which  I  have  seen  in 
other  cases. 

In  this  case,  as  in  the  first  one,  the  inflammatory  action  made  its  ap- 
pearance over  the  insertion  and  along  the  course  of  the  external  rectus 
muscle.  It  is  not  impossible  that  at  first  we  had  to  do  with  a  localized 
inflammation  of  the  capsule  of  Tenon,  which  soon  spread  to  the  loose  orbi- 
tal tissue.  Subsequently  there  was  a  distinct  localized  infiltration  either 
of  the  fibrous  capsule  of  the  eye,  or  of  the  sclera,  or  both,  resembling  so 
strongly  a  gummy  tumour,  which  are  common  enough  at  this  point,  that 
syphilis  was  suspected.  The  vicinity  of  the  external  rectus  muscle  seems 
to  be  the  favourite  seat  of  gummata  of  the  exterior  of  the  eyeball;  but  why 
this  is  so,  is  not  known.  Signs,  of  general  cellulitis  soon  set  in,  however, 
and  the  diagnosis  was  made  easy. 

Another  symptom  in  this  case  which  I  have  also  seen  exceedingly  well- 
marked  in  one  other  case,  was  the  great  pain  in  the  scalp.  It  did  not 
seem  to  start  from  any  particular  point  and  spread  in  different  directions, 
but  appeared  all  over  the  scalp,  sometimes  with  equal  severity  at  all  points, 
at  others  being  most  marked  in  distinct  regions,  as  the  parietal  or  occi- 
pital. Whether  this  is  caused  by  a  neuralgic  condition  of  the  nerves  of 
the  scalp,  starting  from  the  supraorbital  nerve  within  the  focus  of  inflam- 
mation in  the  orbit,  and  extending  to  the  whole  scalp  through  the  medium 
of  the  intricate  anastomoses  ;  or  whether  it  is  due  directly  to  the  general 
turgid  condition  of  the  bloodvessels  of  the  scalp  pressing  upon  the  nerve 
filaments  and  thus  causing  pain,  I  am  not  prepared  to  say.  Either  hypo- 
thesis is  possible,  with  perhaps  the  probability  in  favour  of  the  latter. 

Case  V — Orbital  Cellulitis  following  Iridectomy  for  Glaucoma. — 
T.  B.,  aet.  58,  contractor;  a  large,  very  robust  man;  first  seen  February 
28,  1878.  About  eight  months  before  I  saw  him  he  noticed  that  the 
vision  of  the  right  eye  began  to  fail.  There  has  never  been  any  pain  in 
the  eye,  and  very  little  redness,  but  all  that  he  complained  of  was  that  his 
vision  was  foggy.  He  has  always  been  a  healthy  man,  leading  an  active, 
out-door  life,  and  has  had  no  disease  of  any  kind  except  intermittent  fever, 
from  which  he  has  suffered  at  intervals  for  the  last  four  years.  His  heart 
is  irregular  in  action,  but  there  is  neither  hypertrophy  nor  valvular  dis- 
ease. The  vision  has  slowly  and  steadily  failed  until  it  is  now  reduced  to 
counting  fingers  at  one  foot.    On  examination  the  cornea  was  slightly 


122 


Bull,  Pathology  of  Orbital  Cellulitis. 


[July 


hazy,  like  ground  glass,  the  pupil  moderately  dilated  and  immovable,  the 
fundus  invisible  from  cloudiness  of  the  vitreous,  and  the  eyeball  stony 
hard.  There  was  a  slight  conjunctival  injection  at  the  outer  margin  of 
the  cornea.    The  other  eye  was  normal  in  every  respect. 

A  diagnosis  of  glaucoma  was  made,  and  an  immediate  operation  ad- 
vised. The  patient  declined  this  and  went  away,  but  finally  consented 
on  March  11.  The  operation  was  performed  on  that  day  without  an 
anaesthetic,  a  broad  iridectomy  being  made  upwards.  The  operation  was 
normal  in  every  respect,  though  there  was  considerable  hemorrhage  from 
the  cut  edges  of  the  iris,  which,  however,  was  gradually  worked  out  of 
the  anterior  chamber,  leaving  a  clear  pupil.  In  the  evening  of  the  same 
day  the  patient  was  comfortable,  and  the  tension  was  perceptibly  less. 
The  next  day  the  eye  looked  well,  but  the  wound  had  closed  throughout, 
which  I  regarded  as  an  unfavourable  symptom.  The  tension  had,  how- 
ever, not  increased  again,  and  therefore  the  wound  was  not  reopened,  nor 
was  paracentesis  done.  On  the  second  day  there  was  a  little  oedema  of 
the  margins  of  both  lids,  and  slight  chemosis  of  the  conjunctiva  along  the 
line  of  the  incision,  with  considerable  deep  injection.  Six  leeches  were 
at  once  applied  to  the  temple,  and  cold  applications  were  ordered,  and  the 
wound  immediately  opened,  as  general  inflammation  of  the  eyeball  was 
feared.  But  by  the  next  day  the  signs  of  orbital  cellulitis  were  well 
established.  The  eyelids  were  hot,  red,  and  swollen,  the  conjunctiva  in- 
jected and  chemotic,  and  there  was  already  some  exophthalmus.  The 
inflammatory  action  seemed  to  start  from  the  neighbourhood  of  the  wound 
and  spread  backwards.  The  chemosis  was  most  developed  at  this  point, 
and  there  was  a  distinct  thickening  and  infiltration  of  the  fibrous  capsule 
of  the  eyeball,  which  was  visible  to  the  eye.  At  first  the  most  violent 
symptoms  were  those  of  the  lids.  They  became  enormously  swollen, 
almost  purple  in  colour,  and  the  great  engorged  veins  extended  upwards 
upon  the  forehead,  outwards  upon  the  temple,  and  downwards  upon  the 
cheek,  showing  the  intricate  network  of  anastomoses  of  the  facial  and 
orbital  veins.  The  prominence  of  the  eyeball  increased  very  rapidly,  and 
on  the  fifth  day  after  the  operation  the  cornea,  deeply  sunken  beneath  the 
chemotic  conjunctiva,  became  infiltrated,  the  infiltration  beginning  at  the 
centre,  and  within  twenty-four  hours  involving  the  entire  cornea.  On  the 
evening  of  the  fifth  day  the  patient  had  a  chill,  followed  by  high  fever 
and  profuse  sweating.  The  next  morning  he  had  another  chill,  and  that 
afternoon  a  third.  His  temperature  rose  to  104J°,  and  he  complained  of 
intense  pain  in  the  head.  The  entire  scalp  became  very  sore  and  tender 
to  the  touch.  During  the  night  of  the  sixth  day  he  beeame  delirious,  and 
the  perspiration  was  profuse.  Free  incisions  had  previously  been  made 
into  the  orbit,  the  knife  being  carried  back  to  the  apex  of  the  orbit,  but 
not  a  drop  of  pus  made  its  appearance.  Hot  applications  were  constantly 
made,  and  large  doses  of  quinia  were  administered.  The  veins  of  the 
temple  were  so  enormously  engorged  that  it  was  not  deemed  safe  to  apply 
leeches  here,  but  they  were  applied  on  four  successive  days  behind  the 
ear.  The  patient's  strength  was  rapidly  exhausted,  and  it  became  neces- 
sary to  administer  stimulants  in  small  doses,  in  spite  of  the  continuance  of 
the  grave  head  symptoms.  The  tension  of  the  eye  remained  greatly  above 
the  normal  until  the  cornea  sloughed  on  the  seventh  day.  The  pain  in 
the  eyeball  then  subsided  a  little.  Though  no  pus  made  its  appearance, 
the  repeated  deep  incisions  into  the  orbit  produced  copious  hemorrhages, 
which  seemed  to  relieve  the  patient,  and  the  head  symptoms  diminished 


1878.] 


Bull,  Pathology  of  Orbital  Cellulitis. 


123 


in  intensity.  On  the  fourteenth  day  the  patient  had  a  very  severe  chill, 
followed  by  high  fever  and  a  rapid  and  alarming  return  of  the  head  symp- 
toms. He  complained  of  a  sense  of  fulness,  and  that  evening  a  low  mut- 
tering delirium  set  in.  A  deep  incision  was  made  into  the  outside  of  the 
orbit,  and,  after  the  bleeding  had  ceased,  a  weak  solution  of  carbolic  acid 
was  injected.  This  caused  a  slight  suppuration,  and  the  next  day  the 
patient  was  easier.  From  this  day  the  improvement  was  slow,  but  steady. 
Under  the  continued  use  of  heat  the  swelling  of  lids  and  conjunctiva 
slowly  subsided,  and  the  exophthalmus  receded.  No  discharge  of  pus 
occurred  except  a  slight  one  after  the  use  of  the  carbolic  injection.  The 
tension  of  the  eye  remained  about  normal,  and,  in  spite  of  the  slough  of 
the  cornea,  it  did  not  sink  below  this  standard.  The  patient's  general 
health  gradually  improved,  but  the  turgid  condition  of  the  veins  of  the 
face,  temple,  and  eyelids,  and  the  dusky  hue  of  the  skin  depending  upon 
this,  were  the  last  symptoms  to  yield. 

In  this  case  there  are  several  points  of  unusual  interest.  It  is  fortu- 
nately a  very  rare  accident  that  an  iridectomy  for  glaucoma  should  lead 
to  such  disastrous  results.  It  seems  impossible  to  disregard  the  fact  that 
the  orbital  cellulitis  followed  the  operation  in  the  relation  of  cause  and 
effect.  Inflammation  of  the  orbital  tissue  and  panophthalmitis  have  been 
known  to  follow  the  operation  for  squint,  and  suppuration  of  the  eyeball 
occasionally  results  after  serious  cutting  operations  upon  the  eye,  such  as 
the  extraction  of  cataract ;  but  that  a  simple  iridectomy  should  be  fol- 
lowed by  orbital  inflammation  of  such  a  severe  type  was  a  new  article  in 
pathology,  and  this  is  the  only  case  of  the  kind  that  I  have  ever  heard  of. 
The  inflammation  seemed  to  spread  in  every  direction  from  the  wound; 
this  is  shown  by  the  conjunctival  chemosis  first  appearing  along  the 
wound.  Its  rapidity  was  very  marked,  for  on  the  second  day  there  ap- 
peared the  slight  oedema  of  the  ciliary  margin  of  the  lids,  which  we  have 
seen  in  other  cases.  The  complication  of  malarial  poisoning  with  the 
orbital  trouble  made  it  somewhat  difficult  to  estimate  the  occurrence  of 
the  chills  at  their  proper  value. 

The  enormous  vascular  development  in  the  skin  of  the  eyelids,  face, 
and  temple,  was  an  interesting  feature  in  the  case.  The  great,  distorted 
veins  stood  out  like  knotted  cords  all  over  the  corresponding  side  of  the 
face,  especially  on  the  temple,  and  the  intricate  anastomoses  between  the 
orbital  and  facial  veins  was  very  clearly  shown.  The  amount  of  exuda- 
tion into  and  swelling  of  the  orbital  cellular  tissue  must  have  been  so 
extensive  that  all  venous  communication  between  the  orbit  and  the  cavity 
of  the  skull  was  cut  off,  and  as  no  blood  could  thus  make  its  exit  from 
the  orbit  into  the  cavernous  sinus,  it  was  all  forced  forward  through  the 
orbital  and  ophthalmic  veins,  and  by  their  anastomoses  into  the  branches 
of  the  facial  veins.  The  anterior  and  posterior  facial  veins  are  very  large 
vessels,  and  anastomose  freely  with  each  other  and  with  the  veins  of  the 
scalp.  The  superficial  branch  of  the  anterior  facial,  called  the  angular 
vein,  arises  from  a  union  of  the  frontal,  supraorbital,  palpebral,  nasal,  and 


124 


Bull,  Pathology  of  Orbital  Cellulitis. 


[July 


superior  ophthalmic  veins.    Through  the  frontal  vein  there  is  an  anasto 
mosis  with  the  temporal  and  occipital  vein.    The  palpebral  veins  empty 
partly  into  the  angular  vein,  partly  into  the  temporal,  and  these  latter  are 
again  connected  with  both  anterior  and  posterior  facial  veins. 

Now  if  we  turn  our  attention  to  the  orbit  we  find  that  all  the  veins 
empty  either  backward  into  the  cavernous  sinus,  or  forwards<  into  the 
facial,  or  into  the  vena  ophthalmo-meningea;  and  they  do  so  either  di- 
rectly or  indirectly  through  the  superior  and  inferior  ophthalmic  veins. 
As  regards  the  course  of  the  blood  current,  Sesemann  (Arch,  fur  Anat. 
Phys.  und  Wissenschaftliche  3Iedicin,  18G9)  thinks  that  the  blood  from 
the  orbital  veins  flows  out  not  only  backward  into  the  cavernous  sinus,  but 
also  forwards  into  the  facial  vein,  and  that  the  greater  part  of  the  blood, 
even  in  the  natural  state  of  health,  takes  the  latter  course.  His  reason 
for  this  opinion  is,  that  the  diameter  of  the  collective  openings  into  the 
facial  vein  is  always  greater  than  that  into  the  cavernous  sinus,  the  latter 
being  sometimes  very  small.  Sesemann  regards  the  inferior  ophthalmic 
vein,  moreover,  as  serving  to  conduct  blood  not  only  from  other  orbital 
veins,  but  also  from  the  cavernous  sinus.  He  thinks  that  as  much  blood 
as  can  flows  off  through  the  narrow  opening  into  the  sinus,  and  that  the  rest 
goes  into  the  anterior  facial  vein  through  the  medium  of  the  inferior  oph- 
thalmic vein.  If,  however,  the  pressure  in  the  cavernous  sinus  increases, 
then  the  inferior  ophthalmic  vein  empties  not  only  its  contents,  but  also 
the  blood  from  the  sinus,  into  the  facial.  All  this  is,  of  course,  facilitated 
by  the  numerous  anastomoses  between  the  orbital  veins. 

Now  if  we  have  an  extensive  inflammation  of  the  orbital  tissues,  with 
rapid  and  profuse  infiltration  by  the  products  of  inflammation,  this  loose 
mixture  of  cellular  and  adipose  tissue  becomes  matted  together  into  a 
dense,  brawny  mass.  This  takes  place  just  behind  the  eyeball  towards 
the  apex  of  the  orbit.  It  is  not  unreasonable  to  suppose  that  the  veins 
become  constricted,  and  finally  entirely  obstructed  by  the  mass  of  exuda- 
tion, and  that  the  blood,  not  being  able  to  find  its  way  backward  into  the 
cavernous  sinus,  should  all  be  forced  forward  towards  the  front  of  the 
orbit,  and  thence  into  the  facial,  palpebral,  frontal,  and  temporal  veins. 
This  was  the  picture  presented  by  the  case  of  the  last  patient  cited,  in 
whom  the  various  anastomoses  of  the  facial  vein  were  enormously  en- 
gorged. Why  the  engorgement  was  most  marked  in  the  veins  upon  the 
temple  is  not  clear. 

47  East  Twexty-thtrd  Street,  New  Tork. 


1878.] 


"Woodbury,  Lesion  of  the  Base  of  the  Brain. 


125 


Article  XII. 

Cases  of  Lesion  of  the  Base  of  the  Brain.  I.  Softening  of  Corpus 
Striatum  :  Hemiplegia  not  Developed  until  near  the  Termina- 
tion. II.  Tumour  Invading  Optic  Thalamus  without  loss  of  Sen- 
sibility. BUT  WITH  LOSS  OF  CO-ORDI NATION.  CEREBELLAR  SOFTENING. 
By  Frank  Woodbury,  M.D.,  Assistant  in  Charge  of  the  Medical  Dispen- 
sary of  the  Jefferson  Medical  College  ;  Physician  to  the  German  Hospital, 
Philadelphia,  etc. 

The  principle  laid  down  by  Hughlings  Jackson,  in  his  clinical  studies, 
that  paralysis  and  convulsions  are  not  only  signs  of  disease  but  supply  evi- 
dence bearing  upon  the  localization  of  movements  and  impressions  in  the 
brain  and  the  functions  of  its  component  parts,  opens  a  new  field  and  offers 
a  fresh  incentive  to  clinical  exploration.  He  classifies  the  causes  of  these 
symptoms  under  the  now  familiar  titles  of  "  discharging  lesions"  and  "  de- 
stroying lesions  ;"  and  acutely  observes  that  "  the  phenomena  constantly 
associated  with  such  injuries,  represent  experiments  made  by  disease  upon 
the  human  brain,  in  a  manner  both  imitating  and  supplementing  the  in- 
vestigations made  upon  inferior  animals  by  the  hand  of  the  physiologist."1 
We  find  therefore  that  faithful  clinical  observation  may  contribute  to  the 
progress  of  physiology.  The  fact  that  the  functions  of  the  cerebral  ganglia 
of  Gall,  the  corpora  striata  and  optic  thalami,  are  still  unsettled,  beyond 
the  general  impression,  derived  from  their  anatomical  relations  with  the 
crura  cerebri  and  the  great  motor  tracts,  that  they  are,  in  some  manner, 
connected  with  motion  and  sensation,  furnishes  the  motive  for  publishing 
these  two  interesting  but  isolated  cases,  which  are  offered,  not  in  favour  of 
any  theory,  but  wholly  with  the  desire  to  rescue  from  oblivion  certain 
clinical  and  pathological  farts,  which  may  at  some  future  time,  and  by  some 
abler  pen,  be  made  tributary  to  the  advance  of  medical  science. 

Case  I.  Acute  White  Softening  of  Right  Corpus  Striatum  and  Mid- 
dle Lobe  simulating  Tumour ;  Hemiplegia  developed  towards  termination 
of  Case ;  Death  from  Coma  William  F.,  a  German,  bookkeeper,  sin- 
gle, ret.  36,  came  to  me  for  treatment  January  21,  1875.  He  appeared 
considerably  older,  but  this  was  attributable  to  his  nervous  diathesis. 
With  slight  exceptions,  his  health  had  been  uniformly  good.  He  had 
gonorrhoea  at  twenty-one  without  sequela?.  He  denied  syphilis.  Family 
history  good ;  mother  died  of  old  age,  father,  aged  80,  living  and  well. 
Other  children  healthy,  except  that  one  brother  was  subject  to  attacks  of 
despondency  bordering  on  melancholy,  which  is  noteworthy  in  connection 
with  the  patient's  tendency  to  become  worried  over  trifles.  In  the  begin- 
ning of  1872,  he  had  a  slight  pharyngeal  irritation  and  cough,  and  he 
dwelt  upon  this  condition  constantly,  fearing  consumption,  until  he  became 
almost  hypochondriacal.    After  a  sea-voyage  and  spending  some  months 

1  Clinical  and  Physiological  Researches  on  the  Nervous  System.  No.  1,  On  the 
Localization  of  Movements  in  the  Brain.    London,  1875. 


126 


Woodbury,  Lesion  of  the  Base  of  the  Brain.  [July 


among  his  friends,  his  health  was  greatly  improved,  and  he  continued  well 
up  to  his  present  attack. 

Ordinarily  temperate,  a  few  nights  before  I  saw  him  he  had  drunk  more 
than  usual,  but  not  to  intoxication.  The  night  was  very  cold,  and  before 
retiring  he  bathed  his  face  and  hands  in  cold  water.  He  slept  heavily, 
and  only  partially  covered,  his  left  arm  hanging  over  the  side  of  the  bed. 
In  the  morning  he  complained  of  general  numbness,  muscular  pains  and 
stiffness,  but  his  left  hand  and  forearm  were  completely  powerless. 

When  he  came  under  observation,  motion  had  partially  returned  in  the 
fingers  ;  the  paresis  was  more  marked  in  the  flexors  of  the  forearm  than 
in  the  extensors.  Sensation  was  impaired  on  the  dorsum  of  the  thumb 
and  index-finger,  and  to  a  less  degree  on  the  radial  aspect  of  the  hand 
over  the  first  metacarpal  bone.  He  was  not  prevented  from  attending  to 
his  business  duties. 

In  the  absence  of  other  symptoms,  the  case  was  considered  one  of  radial 
palsy  due  to  cold  and  the  constrained  position  ;  and  treatment  was  instituted 
by  hot  and  cold  douches,  friction,  systematic  exercise,  and  electricity  ;  and, 
in  truth  under  this  regimen  improvement  at  first  was  rapid,  but  soon  a 
stage  was  reached  where  the  arm  continued  about  the  same  from  one  visit 
to  the  succeeding. 

In  the  latter  part  of  February  some  other  features  were  noticed,  which 
imparted  a  new  aspect  to  the  case,  and  suggested  a  lesion  at  the  base  of 
the  brain.  As  the  hand  improved  some  rigidity  appeared,  which  resisted 
flexion  of  the  fingers  and  pronation  and  supination,  but  the  muscles  all 
responded  well  to  the  constant  current.  He  complained  of  some  thickness 
of  the  tongue,  of  an  unaccustomed  difficulty  in  pronouncing  certain  words, 
and  of  occasionally  biting  his  tongue,  which  seemed  too  large  for  his 
mouth,  although  not  really  increased.  He  also  called  attention  to  numb- 
ness of  the  lips,  and  to  the  occasional  accumulation  of  food  on  the  left  side 
of  the  mouth.  The  tongue  and  palatal  arches  showed  no  deviation  ;  hut 
an  inspection  of  that  part  of  his  face  which  had  been  hidden  by  the  beard, 
now  revealed  drooping  of  the  angle  of  the  mouth  on  the  left  side,  and  par- 
tial loss  of  expression. 

On  the  10th  of  March,  the  symptoms  of  glosso-labial  palsy  were  less 
marked.  The  hand  had  nearly  regained  its  power,  and  the  anaesthetic 
area  had  faded  away. 

The  next  afternoon  he  had,  for  the  first  time,  a  fit.  I  saw  him  seated 
in  a  chair  a  few  minutes  later,  conscious,  but  looking  much  dejected.  His 
voice  was  peculiar,  and  a  state  of  mental  erethism  was  shown  by  his  rapid 
ejaculatory  speech  and  whining  tone.  He  had  been  in  his  usual  health  all 
the  forenoon  ;  but  upon  rising  to  accompany  a  friend,  with  whom  he  had 
been  chatting,  to  the  door,  he  fell  forward  to  the  floor.  He  had  vertigo  ; 
but  no  headache,  loss  of  consciousness,  or  muscular  spasm. 

There  was  no  ptosis  or  squint,  pupils  moderately  dilated.  He  read, 
without  hesitation,  from  a  newspaper,  when  requested  to  do  so.  A  watch 
was  heard  at  more  than  two  feet  on  the  right,  but  at  only  one  inch  from 
the  left  ear.  (Deafness  had  not  been  noticed  before.)  Increased  left-sided 
facial  palsy,  with  local  anaesthesia,  was  observed.  Tongue  now  protruded 
to  the  left.  Forearm  again  hung  helpless  at  his  side.  No  cardiac  murmur 
existed,  the  first  sound  was  rather  weak. 

After  taking  some  alcoholic  stimulant,  he  was  able  to  ride  home,  but 
during  the  night  had  another  attack,  and  fell  out  of  bed.  He  now  sought 
admission  to  the  Orthopaedic  Hospital,  under  the  care  of  Dr.  S.  Weir 


1878.] 


Woodbury,  Lesion  of  the  Base  of  the  Brain. 


127 


Mitchell,  to  whose  courtesy  I  am  indebted  for  permission  to  complete 
this  case  from  the  hospital  record  book. 

Ophthalmoscopic  examination  was  entirely  negative.  Sensation  now 
decidedly  impaired  in  the  hand.  Loss  of  power  in  forearm  not  complete, 
nor  confined  to  parts  supplied  by  the  radial  nerve.  Fingers  were  con- 
tracted, and  there  was  also  rigidity  in  the  forearm.  Impairment  of  sensa- 
tion existed  in  the  left  side  of  the  face.  Lie  could  readily  open  and  shut 
both  eyes,  but  closed  them  tightly  only  with  effort.  There  was  loss  of  late- 
ral control  of  the  left  eye  (a  new  symptom).  Tongue  was  protruded  to 
the  left,  but  he  could  turn  it  to  the  right.  He  bit  his  tongue  in  eating, 
but  not  during  sleep.  The  branches  of  the  right  temporal  artery  swollen 
and  tortuous ;  vessels  of  left  temporal  region  were  scarcely  visible.  He 
had  had  continual  throbbing  on  the  right  side  of  his  head  for  years,  con- 
nected with  former  attacks  of  neuralgia. 

For  the  first  few  days  after  entering  the  hospital  he  was  delirious  and 
restless.  The  paralysis  in  the  left  arm  now  became  associated  with  loss 
of  power  in  the  left  leg,  which  steadily  increased.  A  blister  was  applied 
to  his  left  temple  ;  iodide  of  potassium  given  in  five  grain  doses  every 
three  hours,  and  a  drachm  of  bromide  at  bedtime.  Under  this  treatment 
he  apparently  was  improving,  on  March  27th,  but  the  next  clay  there  was 
absolute  loss  of  power  in  the  left  arm  and  leg,  and  incontinence  of  urine  ; 
mind  sluggish,  sleep  disturbed.  Iodide  was  discontinued,  and  mercurial 
inunctions  substituted. 

A  few  days  later,  though  he  answered  questions  more  readily,  the  hemi- 
plegia continued  the  same,  and  ptosis  of  right  eyelid  appeared.  Coma  set 
in.  and  he  died  April  3,  187o. 

An  ophthalmoscopic  examination  two  days  before  death  failed  to  detect 
any  abnormality. 

Autopsy. — Xo  emaciation.  Thoracic  and  abdominal  viscera  healthy  ; 
cardiac  valves  not  diseased.  Vessels  of  membranes  congested ;  longitudi- 
nal sinus  contained  a  large  firm  clot. 

Right  hemisphere  prominent  and  fluctuating  on  its  superior  surface,  in 
the  convolutions  in  front  of  the  fissure  of  Rolando.  Right  middle  cere- 
bral artery  contained  a  firm  clot  from  its  first  bifurcation,  extending  about 
one  inch. 

The  softening  on  the  right  side  extended  nearly  from  surface  to  base, 
parti  all  v  involving  parietal  and  almost  entire  anterior  lobe  ;  the  right  cor- 
pus striatum  being  disintegrated  and  diffluent ;  anterior  margin  of  optic 
thalamus  somewhat  softened. 

The  clot  in  middle  cerebral  artery  was  attached,  and  fully  occluded  the 
vessel.    Puncta  vasculosa  large,  and  dark  coloured. 

Since  no  record  was  made  to  the  contrary,  the  floor  of  the  fourth  ven- 
tricle was  probably  in  general  appearance  healthy.  A  careful  microscopi- 
cal report  of  the  condition  of  the  nuclei  in  the  medulla  oblongata  would 
prove  of  interest  in  view  of  the  glosso-labial  symptoms  (paralysis  of  Du- 
chenne),  and  the  evident  involvement  of  the  portio  dura  and  left  auditory 
nerve.  This  could  not  be  furnished,  as  no  specimens  were  allowed  to  be 
removed. 

Case  II.  Glio-sarcoma  in  Third  Ventricle  encroaching  upon  Left  Optic 
Thalamus ;  Softening  of  Superior  Surface  of  the  Cerebellum ;  neither 
Paralysis,  Convulsions,  nor  Anaesthesia,  but  marked  loss  of  co-ordination 


128 


Woodbury,  Lesion  of  the  Base  of  the  Brain. 


[July 


in  Lower  Extremities ;  Death  from  coma  November  15,  1877,  was  called 

to  see  Thomas  B.,  ret.  45,  Irish,  roofer,  married.  Found  him  com- 
plaining of  vertigo,  headache,  and  a  constant  hissing  sound  in  his  ears, 
like  escaping  steam.  He  could  not  localize  his  headache,  and  no  local  ex- 
planation of  the  tinnitus  could  be  discovered.  There  was  a  harsh  mur- 
mur taking  the  place  of  the  first  sound  at  the  mitral  orifice,  but  the  heart's 
action  was  regular,  and  the  impulse  not  exaggerated.  Appetite  good, 
tongue  slightly  coated,  bowels  constipated,  no  albumen  in  the  urine.  Some 
mental  dulness  was  thought  to  exist,  and  his  memory  was  impaired.  His 
health  was  good  ;  "he  had  never  been  sick  a  day  in  his  life,"  and  his 
wife  testified  that  he  had  not  lost  a  day  from  sickness  for  seventeen  years. 
After  repeated  questioning,  his  sister  recalled  that  fully  five  winters  before 
this  attack  he  had  fallen  from  a  step  and  struck  the  back  of  his  head  with 
great  violence,  but  he  was  able  to  walk  home,  and  went  to  work  as  usual 
the  next  morning.  He  had  not  complained  in  the  mean  time.  He  was  of 
temperate  habits,  and  free  from  venereal  taint. 

He  had  been  exposed  to  the  sun,  and  frequently  during  the  preceding 
summer  complained  of  headache  ;  but  never  had  been  sunstruck.  In  the 
spring  of  1877  he  felt  as  well  as  he  ever  had  in  his  life.  One  day  in 
August,  after  lying  down,  he  noticed  a  general  feeling  of  numbness 
come  over  him,  without  pain  or  paralysis.  Following  this,  however,  he 
occasionally  felt  dizzy.  Being  unable  to  obtain  employment  at  this  time, 
he  did  not  work  again  until  the  early  part  of  November.  Vertigo  now 
annoyed  him  very  much,  and  also  a  peculiar  noise  in  his  ears,  which 
gradually  increased.  One  morning,  after  starting  for  work  and  going  a 
short  distance,  he  could  not  remember  the  way  to  his  accustomed  place  of 
business,  and  was  obliged  to  return  home. 

He  had  sought  medical  advice  Nov.  8th,  but  his  symptoms  were  not 
relieved.  He  staggered  and  stumbled  in  walking  as  if  intoxicated.  The 
tinnitus  also  became  aggravated,  so  that,  on  the  day  before  I  saw  him.  lie 
kept  his  bed.  Previous  to  this  he  could  walk,  but  was  unable  to  main- 
tain his  balance  in  the  dark,  or  with  his  eyes  closed.  He  had  some  numb- 
ness in  his  legs  and  arms,  but  no  actual  loss  of  sensibility.  Some  myopia 
existed,  but  no  changes  were  discovered  by  the  ophthalmoscope,  except 
that  the  disks  were  unusually  red. 

He  was  given  iodide  of  potassium,  increased  to  a  drachm  daily,  with 
frequent  cathartics,  and  blisters  were  applied  behind  the  ears  and  at  the 
back  of  the  neck.  He  rapidly  improved,  and  Nov.  27th  was  allowed  to 
sit  up.  During  this  period  he  had  some  hallucinations,  but  his  symptoms 
at  this  note  had  almost  entirely  disappeared.  Some  mental  lethargy  was 
observed,  which  might  be  habitual  with  him.  On  Dec.  7th  he  went  out  for 
the  first  time.  His  eyes  were  examined  by  Dr.  Little  at  the  Hospital  of 
the  Jefferson  Medical  College,  and  no  evidence  of  disease  detected  ;  there 
was,  on  the  contrary,  rather  less  congestion  of  the  disks.  In  this  improved 
condition  he  had  remained  for  more  than  a  week,  not  attempting  any 
active  exertion,  when  the  symptoms  gradually  reappeared.  It  was  now 
thought  advisable  to  take  him  to  the  Pennsylvania  Hospital,  where  he 
was  received  Dec.  19th,  and  remained  until  Jan.  12,  1878,  under  the 
care  of  Dr.  Da  Costa. 

It  should  be  stated  that  he  had  used  FothergilPs  solution  of  hydrobromic 
acid  to  relieve  the  tinnitus.  The  dose  was  cautiously  increased  to  a  drachm 
three  times  a  day ;  no  effect  being  noticed,  it  was  discontinued.  Bromide 
of  potassium  was  also  tried,  without  any  effect  upon  the  symptoms,  except 
that  it  seemed  to  increase  the  dulness. 


1878.]        Woodbury,  Lesion  of  the  Base  of  the  Brain. 


129 


While  at  the  hospital  the  head-symptoms  remained  about  the  same,  but 
his  staggering  became  more  marked  and  he  had  several  falls.  The  tin- 
nitus and  vertigo  were  constant  when  he  was  sitting  up,  but  less  marked 
and  sometimes  absent  when  lying  down.  He  slept  heavily,  and  felt  better 
when  he  first  rose  in  the  morning  than  afterwards.  He  had  no  paralysis, 
and  answered  questions  intelligently,  but  slowly.  He  was  taken  home 
again  by  his  friends. 

Jan.  12.  Confined  in  bed,  and  given  phosphide  of  zinc  and  nux  vomica, 
and  a  diet  consisting  Largely  of  milk.  About  a  week  afterward,  in  getting 
into  bed,  losing  his  balance  and  trying  to  regain  it,  he  staggered  backward 
across  the  room,  and  fell  against  the  opposite  wall.  His  wife  subsequently 
reported  that  whenever  he  stood  erect  he  had  a  constantly  increasing  ten- 
dency to  stagger  backwards  ;  until,  finally,  towards  the  middle  of  March, 
attempts  at  walking  completely  failed.  When  he  was  supported  on  his 
feet,  the  right  leg  was  spasmodically  thrown  across  the  left,  he  could  not 
make  a  step ;  but  in  the  recumbent  posture,  neither  spasm  nor  paralysis 
could  be  detected.  His  knees  were  unable  to  support  his  body  ;  but  he 
ayus  able  to  accomplish  any  required  muscular  movement,  and  kick  strongly, 
while  lying  upon  his  back. 

In  the  early  part  of  February  divergent  squint  and  diplopia  appeared 
and  became  permanent.  There  was  no  prominence  of  the  globes.  He 
generally  used  his  right  eye,  but  vision  was  unimpaired  in  the  left.  No 
diminution  of  the  area  of  vision  appeared  on  rough  examination  in  either 
eye.  The  eye-grounds  were  normal.  The  slight  strabismus  was  attributed 
to  spasm  of  the  left  external  rectus.  '  From  the  beginning  of  his  illness  he 
showed  complete  disinclination  to  reading,  although  he  had  previously  read 
habitually.    He  had  not,  however,  complained  of  his  eyes. 

For  a  short  period,  fluid  extract  of  ergot  was  given  in  drachm  doses, 
three  times  daily.  He  did  not  get  worse  under  this  treatment,  but  as 
he  did  not  improve,  it  was  decided  to  return  to  full  doses  of  potassium 
iodide,  which  promised  better  results,  but  signally  failed.  Blistering  par- 
tially relieved  the  tinnitus,  but  not  entirely.  On  March  13th,  a  seton  was 
introduced  into  the  back  of  the  neck.  From  this  date  the  noises  and 
headache  entirely  disappeared,  and  he  remained  the  last  month  of  his  life 
free  from  pain.  During  the  last  three  months  he  gained  more  than  twenty 
pounds.    He  had  no  bed-sores. 

In  March  it  was  noticed  that  the  left  leg  was  moved  quite  frequently 
in  bed.  He  had  also  complained  of  some  stiffness  in  the  left  arm,  but  as 
it  was  transitory,  and  he  had  fallen  out  of  bed  a  short  time  before,  it  was 
attributed  to  contusion;  at  all  events  there  was  no  apparent  rigidity., 
and  all  the  movements  and  tactile  sense  were  preserved  unimpaired. 
During  the  last  two  or  three  weeks  he  had  some  difficulty  in  swallowing ; 
the  food  sometimes  seemed  to  nearly  strangle  him,  but  whether  due  to 
spasm  or  paralysis  was  not  determined.  He  now  had  involuntary  alvine 
discharges.  Previously,  however,  he  had  been  unable  to  retain  his  water 
for  any  length  of  time,  and  frequently  passed  it  in  bed.  He  slept  heavily, 
and  occasionally  had  hallucinations.  He  could  not  remember  how  long 
he  had  been  sick,  and  frequently  asked  to  be  allowed  to  get  up  and  go  to 
his  work.  On  the  6th  of  April  he  was  more  lethargic,  and  the  next  day 
unconscious ;  cheeks  and  forehead  flushed,  the  rest  of  the  face  pale,  nose 
pinched,  and  eyes  sunken.  Temperature  of  body  not  elevated ;  but  head 
warmer  than  usual ;  pupils  regular,  responded  slowly  to  light ;  pulse  com- 
pressible, accelerated,  not  very  full;  respirations  twenty-four  in  the  min- 
No.  CLI  July  1878.  9 


130  Woodbury,  Lesion  of  the  Base  of  the  Brain. 


[July 


ute,  sometimes  sighing.  Hypostatic  congestion  of  both  lungs  existed; 
the  heart's  action  was  failing;  the  right  cavities  overloaded.  Congestion 
of  the  lungs  and  brain  being  present,  he  was  ordered  two  drops  of  croton 
oil  at  once,  to  be  repeated  in  two  hours ;  turpentine  stupes  to  the  chest  and 
abdomen,  and  sinapisms  to  calves  of  legs.1  A  rubber  cushion  containing 
ice-water  was  placed  under  his  head,  and  cold  compresses  applied.  In 
the  evening  the  circulation  had  become  equalized;  his  breathing  natural; 
he  had  no  cough  nor  fever;  the  bowels  had  been  opened  freely  three 
times.  The  next  morning  he  recognized  his  wife,  ate  breakfast,  and  con- 
versed with  his  friends.  The  difficulty  in  swallowing  still  continued,  but 
no  paralysis  nor  muscular  spasm  existed  in  the  extremities;  he  moved  all 
of  them  with  equal  facility.  During  the  next  few  days  he  gradually  be- 
came comatose,  and  died  April  10th.  1878. 

Autopsy  made  by  Dr.  Morris  Lonystreth  (from  whose  report  the  fol- 
lowing is  condensed)  Heart  slightly  enlarged,  mitral  valves  thickened 

by  old  deposit;  lungs  partly  consolidated  (hypostatic  pneumonia).  Brain 
firm,  convolutions  decidedly  flattened,  membranes  slightly  congested; 
deposit  resembling  connective  tissue  in  interpeduncular  space,  where  part 
of  third  nerve  was  included  and  bound  down,  and  arachnoid  was  thick- 
ened and  adherent.  Tumour,  size  of  walnut,  found  in  third  ventricle, 
moulded  to  the  interior.  Pressed  surrounding  structures  in  all  directions. 
It  was  wedge -like  above,  broad  below,  extending  to  base  of  brain  just 
above  corpora  albicantia,  and  forwards  as  far  as  anterior  commissure.  A 
caudate  prolongation  completely  blocked  up  the  iter  e  tertio  ad  quartern 
ventriculum.  Owing  to  this  obstruction,  a  large  quantity  of  serum  had 
been  imprisoned,  enormously  distending  the  fourth  and  to  a  less  extent 
the  lateral  ventricles. 

The  growth  invading  the  left  optic  thalamus  contained  small  hemor- 
rhagic areas;  its  outline  was  not  well  defined,  as  it  shaded  oft' into  normal 
tissue,  penetrating  and  pushing  the  parts  asunder;  corpus  striatum  and 
internal  capsule  not  implicated;  right  geniculate  bodies  unaltered,  left 
scarcely  distinguishable,  and  corpora  quadrigemina  separated  and  flattened  ; 
fornix  softened  posteriorly;  ventricular  walls  not  softened.  Medulla  ob- 
longata widened,  nuclei  not  atrophied.  Lett  crus  cerebri  and  optic  tract 
flattened,  not  otherwise  changed. 

Tumour  originated  in  gray  matter  of  middle  commissure  or  left  optic 
thalamus,  and  grew  across  to  the  right ;  no  other  attachments  existed. 
Superior  surface  covered  by  ventricular  ependyma,  and  striatum  zonale  of 
left  optic  thalamus;  it  presented  the  characteristics  of  glio-sarcoma. 

Left  optic  globe  examined.  Outline  of  disk  irregular,  not  prominent  ; 
vessels  obscured  at  border,  and  appeared  to  dip.  (This  may  have  been 
merely  a  post-mortem  appearance.) 

Superior  surface  of  cerebellum  showed  an  area  of  softening  from  median 
line  to  middle  of  right  hemisphere,  and  from  cortex  to  medullary  area, 
the  latter  was  not  involved. 

Briefly  reviewing  a  few  of  the  prominent  points,  it  is  noticed  that  in 

1  According-  to  the  observations  of  Schiiler,  a  warm,  wet  compress  applied  to  the 
belly  or  back,  is  immediately  followed  by  a  more  or  less  energetic  and  persistent  con- 
traction of  the  vessels  in  the  pia  mater  in  trephined  animals.  They  may  thus  act, 
as  remarked  by  Winternitz,  as  do  pediluvia  and  sinapisms  to  the  abdomen,  by  dimin- 
ishing the  amount  of  the  blood  in  the  brain. — London  Practitioner,  April,  1878,  p. 
253. 


1878.]        Woodbury,  Lesion  of  the  Base  of  the  Brain. 


131 


the  former  patient  the  primary  symptom  was  the  radial  paralysis.  Two 
explanations  of  this  case  suggest  themselves.  First,  the  cerebral  affection 
preceded  the  palsy.  There  was  atheroma  of  the  smaller  vessels,  impaired 
circulation,  mal-nutrition,  and  finally  degeneration  of  that  portion  of  the 
ascending  frontal  convolution  containing  the  motor  centre  for  the  left 
arm  (Hitzig).1  Stasis  and  coagulation  took  place  in  the  capillaries  of 
this  area.  At  the  time  of  his  fit,  the  clotting  ran  backward  to  the  ves- 
sels at  the  base.  Softening  occurred,  because  the  disease  of  the  minute 
vessels  prevented  the  establishment  of  the  collateral  circulation. 

The  second  hypothesis  is,  that  the  paralysis  of  the  arm  was  rheumatic, 
and  it  preceded  and  invited  the  disease  of  the  motor  area,  from  suspension 
of  function,  a  pre-existing  vascular  degeneration  favouring  this  condition. 
The  subsequent  course  being  the  same. 

The  first  supposition  appears  more  plausible,  but  the  latter  is  by  no 
means  improbable.  We  know  that  muscles  in  a  state  of  rest  have  their 
blood-supply  diminished,  while  during  action  it  is  increased  ;  that  the 
secreting  glands  follow  the  same  law ;  that  the  hemispheres  themselves  have 
their  circulation  increased  by  emotion  and  sustained  attention.  May  not 
this  occur  in  any  other  nervous  centre  when  its  functions  are  elevated  ?  If 
so,  then  a  depression  of  function  should  diminish  tissue-changs  and  blood- 
supply,  and  such  a  condition  exists  in  rheumatic  palsy,  or  after  amputa- 
tion. In  truth,  this  view  receives  strong  confirmation  from  the  observa- 
tion recently  made,  that  after  amputation  of  a  limb  the  corresponding  area 
in  the  brain  shows  atrophy  to  a  remarkable  degree.2 

Either  view  is  on  the  ground  that  there  was  disease  of  the  small  ves- 
sels, and  that  the  condition  was  one  of  thrombosis  rather  than  embolism. 
The  facts  that  the  heart  was  absolutely  healthy,  and  that  there  were  no 
embolic  patches  in  the  lungs  or  other  viscera,  warrant  this  assumption. 
It  is  also  believed  that  the  plugging  preceded  the  acute  softening,  since  it 
has  been  positively  declared  by  an  eminent  observer  to  be  the  law  of  this 
condition. 

Sufficient  local  cause  appeared  to  exist  for  the  radial  palsy  in  the  con- 
strained position  and  cold,  and  it  is  not  denied  that  this  may  have  been 
entirely  disconnected  from  the  central  disorder,  except  through  the 
coincidence  of  the  subsequent  hemiplegia  of  the  left  side.  The  supposi- 
tion that  the  rheumatic  paralysis  was  primary,  indeed  offers  the  simplest 
explanation  of  the  appearance  of  the  anaesthetic  area  on  the  hand. 

In  regard  to  the  two  weeks'  delay  of  the  hemiplegia  after  the  throm- 

1  Franck  and  Pitre's  experiments,  and  the  analysis  of  cases  in  M.  Charcot's  wards, 
also,  serve  to  indicate  that  paralysis  predominates  in  the  upper  extremity  when  the 
lesion  is  most  marked  in  the  anterior  part  of  the  internal  capsule,  as  it  was  in  this 
case. — Monthly  Abstract,  from  London  Med.  Record,  Feb.  15,  1878. 

2  Case  of  M.  Proust,  presented  to  French  Hospital  Society,  Boston  Med.  and  Surg,. 
Journal  for  May  16,  1878,  from  Medical  Examiner. 


132 


Woodbury,  Lesion  of  the  Base  of  the  Brain. 


[July 


bosis,  it  is  possible  to  assume  either  that  the  arterial  trunk  was  not  com- 
pletely occluded  until  this  period,  or  that  the  paralysis  signalized  the 
onset  of  softening. 

Case  II.  was,  at  first,  looked  upon  as  one  of  chronic  basal  meningitis ; 
but  this  view  was  subsequently  excluded  by  the  course  of  the  disease. 
There  was  no  fever,  although  the  record  was  kept  for  weeks  at  a  time  ; 
there  was  neither  vomiting,  cramps  in  the  limbs,  nor  convulsions.  He 
never  had  excitement  nor  active  delirium.  The  examination,  it  is  true, 
revealed  a  small  amount  of  thickening  of  arachnoid  and  new  deposit  at 
the  base,  which  was  probably  sufficient  to  account  for  the  strabismus 
through  the  involvement  of  the  trunk  of  the  third  nerve. 

The  involuntary  fecal  discharges  before  the  appearance  of  coma,  pointed 
to  a  discharging  lesion  at  the  base  of  the  brain,  i.  e.,  a  tumour;  and  it  has 
been  frequently  observed  that  involuntary  alvine  evacuations  occur  in  a 
certain  number  of  cases,  as  the  primary  symptom  of  tumour  at  the  base 
of  the  brain. 

The  staggering  backward  strikingly  recalled  the  physiological  experi- 
ments of  Magendie  and  others,  and  led  to  a  diagnosis  of  disease  of  the 
upper  surface  of  the  cerebellum,  which  was,  indeed,  softened,  although  the 
tumour  was  not  beneath  the  tentorium,  as  had  been  anticipated.  In  con- 
nection with  this  lesion  of  the  cerebellum  it  is  proper  to  state  that  per- 
sistent priapism  did  not  exist,  and  during  the  latter  part  of  the  disease 
there  were  no  erections  whatever.  In  view  of  the  fact  that  direct  com- 
munication has  been  shown  by  Meynert  to  exist  between  one  half  of  the 
cerebellum  and  the  opposite  optic  thalamus,  it  is  perhaps  significant  that 
the  crossed  lesion  existed  in  this  case. 

That  there  was  no  actual  paralysis  of  sensation  may  be  thought  to  be 
due  to  the  fact  that  the  optic  thalamus  was  not  sufficiently  destroyed  to 
produce  entire  abolition  of  its  function.  It  is  acknowledged,  however, 
that  a  general  sense  of  numbness  existed,  hut  it  was  not  confined  to  one 
side.  May  not  this  observation,  coupled  with  the  fact  that  the  tumour 
grew  across  in  the  gray  commissure  from  the  left  optic  nucleus  to  the 
right,  warrant  the  view  that  these  bodies  ordinarily  act  as  a  unit,  not  un- 
like the  gray  matter  of  the  spinal  cord  ?  And  the  experiments  of  Brown- 
Sequard  upon  the  spinal  cord  have  shown  that  a  relatively  greater  destruc- 
tion of  gray  matter  is  required  to  paralyze  sensation  than  to  abolish 
motion. 

The  fact  that  hemi anaesthesia  was  not  present  is  quite  in  conformity 
with  the  experiments  of  Veyssiere,1  who  found  that  this  does  not  occur 
from  destruction  of  the  optic  thalamus  in  dogs,  unless  the  internal  capsule 
is  also  injured. 

The  early  tinnitus  aurium  and  vertigo,  with  impaired  hearing,  suggested 


1  Kecherches  sur  l'Hemiana?sthesie  de  cause  eerebrale.    Paris,  187-1. 


1878.]        Messemer,  Cold  Water  Enemata  in  Diarrhoea. 


133 


Meniere's  disease,  and  it  is  rather  unfortunate  that  the  internal  ear  was 
not  made  the  subject  of  careful  study.  It  is  thought,  however,  that  a 
sufficient  central  cause  existed  for  the  appearance  of  these  symptoms. 

It  is  very  noticeable  that  this,  which,  being  in  an  otherwise  healthy 
man,  approached  as  nearly  as  possible  the  condition  of  an  uncomplicated 
tumour  of  the  brain,  should  have  been  accompanied  by  so  few  of  the 
symptoms  that  are  ordinarily  considered  characteristic.  He  had  no  in- 
tense, persistent  headache,  no  vomiting,  no  general  or  peripheral  paralysis, 
no  facial  palsy,  and,  above  all,  no  choking  of  the  optic  disks.  Tonic  mus- 
cular spasm  was  not  present  to  any  decided  extent  ;  the  affections  of  the 
eye-muscles  and  the  oesophagus  were  the  only  motor  disturbances  present, 
il  we  except  the  loss  of  co-ordination  in  the  lower  extremities,  which 
approached  this  condition. 

The  remote  history  of  injury  seems  to  coincide  with  the  view  expressed 
by  Obermier  that  gliomata  may  result  from  injury  to  the  skull,  and  he 
observes  that  the  history  of  such  an  occurrence  furnishes  one  of  the  points 
in  the  differential  diagnosis  between  cancer  of  the  brain  and  a  gliomatous 
tumour.1 

It  is  to  be  remarked  that  no  aid  in  the  diagnosis  was  furnished  by  the 
ophthalmoscope  in  either  case,  although  the  eyes  were  repeatedly  exam- 
ined by  different  observers. 


Article  XIII. 

Cold  Water  Enemata  as  a  Therapeutic  Agent  in  Chronic  Diar- 
rhoea. By  Michael  J.  B.  Messemer,  M.D.,  Physician  for  Internal  Dis- 
eases in  the  Out-door  Department  of  the  Mount  Sinai  Hospital,  New  York. 

Case  I  On  July  18,  1877,  I  was  called  to  see  a  boy  four  years  of 

age  (the  little  son  of  Mr.  M.,  residing  at  204  Broome  Street),  where  the 
following  history  was  elicited  : — 

The  first  summer  of  the  child's  life,  when  only  six  months  old,  he  was 
attacked  with  summer  complaint  (the  ordinary  entero-colitis  of  young 
children),  which  was  treated  by  Dr.  W.,  who  was  successful  as  far  as 
the  acute  symptoms  were  concerned,  but  he  was  unable  to  control  the 
diarrhoea  entirely.  After  having  treated  the  case  about  one  year,  and 
acute  symptoms  returning  in  the  summer,  he  was  discharged,  and  the 
child  was  put  under  the  care  of  Drs.  A.  and  T.  The  only  result  their 
treatment  had  was  to  put  the  child  under  the  influence  of  opium,  but  the 
boy,  being  of  a  rachitic  and  very  delicate  appearance,  always  had  more  or 
less  diarrhoea  during  their  treatment,  and  had  never  learned  to  walk. 
Thus  far  he  had  not  gained  strength  nor  lost  much,  but  later  on  he 
seemed  to  grow  weaker  and  weaker,  and  Drs.  A.  and  T.  said  he  Avould 
finally  die  of  inanition. 

1  Article  on  Cerebral  Tumours  in  Ziemssen's  Encyclopaedia,  vol.  xii.  p.  263. 


134 


Messemer,  Cold  Water  Enemata  in  Diarrhoea. 


[July 


Status  Prcesens — The  child  'was  small  for  his  age.  He  had  a  very 
cachectic  and  emaciated  appearance.  The  temperature  in  the  evening 
was  102°  Fahr.  in  the  rectum.  The  abdomen  was  distended  with  gas; 
there  was  some  tenderness  in  the  left  iliac  fossa.  lie  was  slightly  de- 
lirious, and  had  about  twenty  passages  that  day.  The  stools  were  of  a 
dark-grayish  colour,  tinged  with  a  little  blood,  and  contained  some  of  the 
ingesta.  In  fact,  to  use  the  father's  words,  everything  passed  through 
except  whiskey  and  water,  but  he  was  not  sure  that  even  that  was  re- 
tained.   Everything  else  he  could  see  in  the  stool,  even  milk. 

The  child  was  given  bismuth  gr.  v,  and  pepsin  gr.  i,  every  two  hours, 
and  no  other  nourishment  but  brandy  and  water  in  the  following  twenty- 
four  hours.  He  was  also  ordered  injections,  per  rectum,  of  a  quart  of 
ice-water  after  every  passage,  but  only  in  portions  of  half  a  pint  at  a 
time,  and  after  every  injection  the  exit  of  the  water  was  to  be  facilitated 
or  assisted  by  the  hand  being  placed  on  the  abdomen,  and  thus  pressure 
exerted. 

On  July  22,  1877,  the  child  looked  brighter,  the  temperature  was  re- 
duced to  10O§°  in  the  rectum  (in  the  evening).  The  number  of  passages 
had  been  reduced  to  eight  in  twenty-four  hours.  The  child  was  ordered 
milk  with  a  little  lime-water.    This  was  well  borne. 

On  the  25th  of  July,  the  number  of  passages  being  reduced  to  four  in 
twenty-four  hours,  and  the  temperature  normal,  he  was  ordered  beef-tea, 
which  was  also  well  borne. 

August  4.  The  child  looked  bright,  and  sat  up  in  bed,  played  with  his 
bed-clothes  and  toys  (something  he  had  not  done  before  during  his  long 
illness).  He  was  now  permitted  to  eat  even  fruit  and  vegetables,  which 
were  also  well  borne. 

Sept.  13.  The  boy  has  been  eating  everything  except  meat,  looks  very 
well,  and  can  walk  short  distances. 

20^/*.  He  has  had  an  increased  number  of  passages,  as  many  as  seven 
in  twenty-four  hours,  which  I  attribute  to  the  parents  having  omitted  the 
cold-water  injections,  and  permitted  the  child  to  eat  hard-boiled  meat. 
Ordered  renewal  of  cold-water  injections. 

24f/?.  Child  is  better,  and  bright  again,  the  number  of  passages  being 
reduced  to  one  a  day. 

Nov.  11.  The  boy  walked  into  my  office,  accompanied  by  his  father. 
He  looked  pale,  but  hearty,  and  was  able  to  run  and  play  as  if  he  had 
never  been  sick.  We  still  continued  the  cold-water  injections,  however, 
omitting  them  only  when  constipation  came  on,  for  which  a  tablespoonful 
of  olive  oil  was  given,  which  would  regulate  the  little  fellow's  bowels. 
He  was  also  put  upon  cod-liver  oil,  with  very  good  results. 

Feb.  20,  1878.  The  child  is  looking  remarkably  plump  and  well.  All 
treatment  was  discontinued  after  this  date.  He  has  been  quite  well  till 
date. 

Case  II  K.  P.,  of  No.  332  East  Fifty-ninth  Street,  native  of  Ireland, 

29  years  of  age,  single.  Had  no  sickness  of  any  account,  except  when  a 
child  had  smallpox. 

In  the  early  part  of  June,  1877,  patient  was  seized  with  an  acute  diar- 
rhoea, which  soon  subsided:  A  short  time  after,  she  again  found  her  stools 
becoming  watery,  and  the  number  of  her  passages  were  increasing.  She 
then  consulted  Dr.  H.,  who  treated  her,  but  without  success.  Finding 
his  patient  growing  weaker,  he  advised  her  to  go  to  a  hospital  for  treat- 
ment.   There  her  treatment  first  consisted  of  hypodermic  injections  of 


1 878. J        3Iessemer.  Cold  Water  Enemata  in  Diarrhoea. 


135 


morphia,  followed  by  tannin  and  opium  internally,  which  had  no  effect 
n p o n  the  diarrhoea;  then  bismuth  was  added,  but  in  spite  of  all  this  treat- 
ment the  passages  increased  to  such  an  extent  that  the  patient  avers  she 
counted  nearly  forty  passages  in  twenty-four  hours. 

The  tannin,  opium,  and  bismuth  were  finally  stopped,  and  the  patient 
was  put  upon  brandy  and  water,  with  a  little  milk.  This  latter  treatment 
had  a  comparatively  good  effect,  as  it  reduced  the  passages  to  three  or 
four  a  day,  which  continued  so  until  she  left  the  hospital  on  the  22d  of 
November.  1877.  She  then  placed  herself  under  the  treatment  of  Dr.  C, 
who  gave  her  powder,  pills,  and  a  medicine,  which  would  check  the 
diarrhoea  for  one  day  ;  but  it  would  return  on  the  following  day  in  spite 
of  continued  use  of  the  remedies.  The  patient  remained  under  this  treat- 
ment until  the  16th  of  January,  1878,  when  she  applied  for  treatment  to 
me  at  the  out-door  department  of  the  Mount  Sinai  Hospital,  stating  that 
she  was  given  up  by  her  physicians,  and  that  the  doctor  had  inquired  of 
members  of  her  family  if  she  still  lived. 

Her  present  condition  is  as  follows :  She  has  had  between  thirty  and 
forty  passages  the  preceding  twenty-four  hours,  and  nearly  the  same 
number  during  the  day  for  some  time  previous.  There  was  no  blood  in 
the  discharges,  but  some  mucus.  She  had  much  tenesmus.  Her  food 
passed  from  her  as  she  took  it.  Rectal  examination  proved  negative. 
She  was  very  much  emaciated,  and  complained  of  weakness  and  lassitude. 
Temperature  102|c  in  the  axilla.  The  abdomen  was  distended;  some 
tenderness  manifested  on  pressure,  though  not  particularly  localized. 

She  was  given  the  bicarbonate  of  soda  internally,  and  ordered  to  in- 
ject a  quart  of  cold  water  (in  divided  portions)  after  each  passage.  The 
exit  of  the  water  was  to  be  brought  about  by  pressure  made  upon  the 
abdomen.  After  the  water  had  been  expelled,  the  patient  was  to  take 
a  small  quantity  (say  about  half  a  tea-cup)  of  cold  water,  and  inject 
slowly,  so  as  not  to  excite  any  peristaltic  action.  This  small  amount  of 
cold  water  was  to  be  retained  by  the  patient,  and  serves  to  keep  the  walls 
of  the  rectum  from  coming  in  contact.  The  patient  was  also  allowed  to 
take  ten  drops  of  the  tincture  of  opium,  if  the  tenesmus  persisted.  Her 
diet  was  to  be  milk  and  brandy,  toast,  and  beef-tea. 

The  patient  returned  on  the  20th,  reporting  that  her  passages  were  re- 
duced to  four  in  twenty-four  hours.  Her  temperature  was  99  £°  in  the 
axilla.  Her  general  appearance  was  better.  She  stated  that  she  had 
felt  hungry  and  ate  vegetables.  She  was  ordered  to  continue  the  treat- 
ment. 

On  the  26th  the  patient  returned,  stating  that  she  had  no  passage 
during  the  past  two  days.  The  treatment  was  suspended,  and  patient 
ordered  to  return  on  the  28th.  She  did  not  return,  however,  until  the 
9th  of  February,  when  she  stated  that  her  diarrhoea  had  returned  the  last 
two  days,  and  that  the  number  of  her  ^passages  were  about  eight  during 
that  time.  Treatment  ordered  to  be  resumed.  She  returned  on  the  18th, 
stating  that  she  felt  as  well  as  though  she  had  never  been  attacked  with 
sickness.  Has  a  good  appetite,  and  but  one  passage  a  day.  Her  tem- 
perature was  normal,  and  she  was  gaining  in  flesh. 

I  saw  her  on  the  22d  March;  she  was  then  quite  well,  and  had  but  one 
passage  daily. 

Case  III — A.  K.,  33  years  of  age,  native  of  Germany,  residing  at  139 
Forsyth  Street,  married  thirteen  years,  and  has  four  children. 

In  her  youth  she  suffered  from  chlorosis.    Nine  years  ago  had  varioloid. 


136  Messemer,  Cold  Water  Enemata  in  Diarrhoea.        [ July 


In  June,  1876,  the  patient  commenced  suffering  from  diarrhoea,  w  hich 
was  so  severe  that  she  was  obliged  to  call  in  a  physician  on  the  second  day 
of  her  illness.  At  that  time  the  number  of  her  stools  were  about  twenty 
in  every  twenty -four  hours.  Her  physician  treated  her  with  tinct.  catechu 
and  bismuth  internally  ;  lie  also  gave  her  iced  red  wine  and  cognac  to  drink. 
This  treatment  somewhat  reduced  the  number  of  passages.  The  diarrhoea 
persisting,  however,  she  was  ordered  injections  of  starch  and  opium.  She 
continued  under  this  treatment  until  about  the  middle  of  September,  when 
she  consulted  Dr.  L.,  who  prescribed  pepsin  and  opium  to  be  taken  inter- 
nally, and  ordered  her  to  take  hot  sitz-baths  (hip-baths).  She  was  under 
this  treatment  about  a  month.  The  patient  then  placed  herself  under  the 
care  of  Dr.  C,  who  treated  her  with  opium  and  tannin  internally,  injec- 
tions of  tannin,  and  suppositories  of  morphia  and  iodoform  per  rectum. 
This  treatment  was  continued  with  some  benefit. 

Her  means  becoming  exhausted,  she  presented  herself  for  treatment  to 
me  at  the  out-door  department  of  the  Mount  Sinai  Hospital  about  the  middle 
of  February,  1878. 

Her  history  at  that  time  was  as  follows  :  She  had  about  eight  passages 
daily,  followed  by  persistent  tenesmus.  She  had  pain  in  the  sacral  region, 
and  occasionally  pain  in  the  hypogastric  region. 

Her  discharges  were  always  thin  and  watery,  of  a  grayish  colour,  and 
accompanied  by  mucus  and  blood.  Her  appetite  was  poor,  and  her  gene- 
ral condition  indicated  great  debility.  She  was  quite  reduced  in  flesh, 
and  a  marked  contrast,  as  she  says,  to  what  she  formerly  was. 

Rectal  examination  proved  negative.  The  urine  was  of  an  acid  reac- 
tion.   Spec.  grav.  1020.    Contained  no  albumen. 

She  was  put  upon  cold  water  injections,  and  bicarbonate  of  soda  was 
given  internally  as  a  placebo. 

In  one  week  her  passages  were  reduced  to  one  per  day.  The  blood  and 
mucus  had  disappeared  after  the  third  day.  There  was  no  tenesmus  after 
the  first  injection. 

On  the  6th  of  April,  1878,  I  saw  the  patient.  She  states  that  she  had 
been  entirely  well  since  the  first  week  of  treatment,  and  that  she  had 
gained  flesh  and  weight  correspondingly.  Her  appearance  verified  her 
assertions. 

The  idea  of  treating  chronic  diarrhoea  with  injections  suggested  itself  to 
me  after  having  treated  some  cases  of  dysentery.  The  tormina  and  tenes- 
mus accompanying  dysentery  I  have  treated  by  injections  of  cold  water 
and  opium,  and  cold  water  alone.  In  my  opinion  these  injections  relieved 
the  tenesmus  and  tormina,  as  it  washed  out  the  irritating  substances,  and 
thus  cleansed  the  rectum,  and  lessened  its  irritability,  and,  as  it  appeared 
to  me,  that  the  increased  number  of  passages,  which  continue  through 
chronic  diarrhoea,  were  due  to  increased  sensibility  and  irritability  of  the 
rectum,  which  was  kept  up  by  irritating  material,  such  as  mucus  and  freces 
contained  therein  (as  the  majority  of  cases  of  constipation  are  due  to 
decreased  sensibility  and  habit),  I  entertained  the  notion  that  by  cleans- 
ing the  rectum  of  such  irritating  matter  by  injections  the  exciting  cause 
or  influence  might  be  removed,  or  at  least  relieved  or  rather  mitigated. 

Consequently  I  made  experiments  at  first  with  warm  water  injections 


1878.]        Messemer,  Cold  Water  Enemata  in  Diarrhoea.  137 


(as  it  occurred  to  me  warm  water  would  certainly  be  as  efficient  if  not 
more  so  than  cold  in  cleansing  the  rectum)  on  myself,  when  I  had  one 
passage  daily  in  the  early  part  of  last  summer.  I  found  that  after  the 
warm  water  injections  had  been  continued  a  few  days  the  stools  would 
become  watery,  and  in  a  week  or  ten  days  the  number  of  passages  would 
be  increased,  a  few  days  thereafter  the  number  of  stools  would  again  be 
reduced,  still  there  would  be  more  than  one  passage  per  diem,  and  that 
the  stools  would  remain  watery.  By  this  experiment  I  found  that  simply 
removing  the  irritating  mucus  or  faeces  by  warm  water  (which  certainly 
removed  them)  would  not  attain  the  result  that  I  had  ascribed  to  it. 

Thereupon  I  injected  cold  water  after  each  passage,  and  found  that  the 
number  of  stools  decreased.  I  kept  on  with  cold  water  injections,  which 
brought  on  constipation.  It  was  found  necessary  to  relieve  this  constipa- 
tion with  a  cathartic. 

I  experimented  upon  myself  at  various  times  since  with  the  same  result. 
I  also  experimented  upon  others  and  found  that  cold  water  injections  con- 
tinued after  each  passage  would  bring  on  constipation.  A  cathartic  would, 
however,  quite  readily  relieve  this  constipation  in  every  case. 

These  experiments  show  that  cold  water  possesses  astringent  properties. 
Its  anodyne  properties  have  long  been  proven  in  dysentery.  Moreover, 
the  water  acts  as  a  protectant  to  the  mucous  membrane  of  the  rectum ; 
when  slowly  injected,  so  as  not  to  excite  peristaltic  action,  it  will  keep 
the  rectum  distended,  and  its  Avails  apart,  thereby  preventing  their  irri- 
tating each  other,  as  it  makes  it  impossible  for  them  to  come  in  contact 
until  the  water  thus  injected  is  absorbed. 

In  the  treatment  of  chronic  diarrhoea  I  do  not  object  to  internal  treat- 
ment being  added  to  the  cold  water  injections,  but  I  consider  dieting  the 
patient  properly,  in  aggravated  cases,  of  the  highest  importance,  for 
obvious  reasons. 

I  have  carefully  studied  both  the  American  and  foreign  literature  on 
the  subject  as  far  as  accessible.  On  searching  Schmidt's  Jahrbucher,  Vir- 
chow's  Jahresberichte,  etc.,  I  find  that  some  German  authors  (Winternitz, 
Monti,  Range)  had  indeed  used  cold  water  injections  in  acute  diarrhoea, 
but  combined  with  other  hydro-therapeutic  measures.  Dr.  Winternitz, 
for  instance,  used  cold  water  injections  in  the  diarrhoea  of  children,  but 
at  the  same  time  applied  cold  water  compresses  over  the  abdomen.  No 
mention,  however,  is  made  of  cold  water  injections  for  the  treatment  of 
chronic  diarrhoea  in  either  the  European  or  American  literature  as  far  as 
I  have  been  able  to  ascertain. 


138 


Forbes,  Harvey  and  the  Transit  of  the  Blood.  [Jul)' 


Article  XIV. 

Harvey  and  the  Transit  of  the  Blood  from  the  Arteries  to  the 
Veins  u  Per  Porositates."  By  W.  S.  Forbes,  M.D.,1  Senior  Surgeon 
to  the  Episcopal  Hospital,  Philadelphia. 

In  the  life  of  Harvey,  written  by  Doctor  Robert  Willis,  and  prefixed 
to  his  translation  of  the  works  of  Harvey,  page  xli.,  published  by  the  Sy- 
denham Society,  in  1847,  we  find  this  assertion:  "  For  Harvey,  it  must 
be  observed,  left  the  doctrine  of  the  circulation  as  an  inference  or  induc- 
tion only,  not  as  a  sensible  demonstration."  Again  :  "  His  [Harvey's] 
idea  of  the  way  in  which  it  was  accomplished  [transit  of  the  blood  from 
the  arteries  to  the  veins]  was  even  defective  ;  he  had  no  notion  of  one 
order  of  sanguiferous  vessels  ending  by  uninterrupted  continuity,  or  by  an 
intermediate  vascular  network,  in  the  other  order." 

In  Sharpey  and  Quain's  Anatomy  (see  "capillaries"),  we  find  the  fol- 
lowing statement :  "  That  the  blood  passed  from  the  arteries  into  the  vein- 
was  of  course  a  necessary  part  of  the  doctrine  of  the  circulation,  as  demon- 
strated by  Harvey;  but  the  mode  in  which  the  passage  took  place  was  not 
ascertained  until  some  time  after  the  date  of  his  great  discovery."  The 
words  "  not  ascertained"  in  this  paragraph  are  guarded,  yet  the  impression 
is  decidedly  made  that  Harvey  did  not  have  the  idea  of  the  way  in  which 
the  blood  is  conveyed  from  the  arteries  to  the  veins.  The  same  statement 
has  been  made  by  others. 

In  a  lecture  delivered  at  the  Royal  Institution,  London,  on  the  25th  of 
January  last,  Mr.  Huxley  is  reported  as  having  said  :  u  One  thing  Harvey 
could  not  do,  because  the  instruments  of  the  time  would  not  enable  him  to 
do  it.  He  never  gave  the  exact  channels  by  which  the  blood  passes  into 
the  veins.". — British  Medical  Journal,  Feb.  2,  1878. 

Harvey's  treatise,  written  in  Latin,  was  published  first  at  Frankfort,  in 
1628.  It  is  a  fact  that  the  compound  microscope,  consisting  of  two  lenses 
placed  at  a  distance,  so  that  the  one  next  the  eye  magnifies  the  enlarged 
image  of  any  object  placed  in  front  of  the  other,  was  invented  by  Hans 
Zansz,  who,  with  his  son,  Zacharias  Zansz,  were  spectacle  makers  at  Mid- 
dleburg,  in  Holland,  about  the  year  1590.  One  of  their  microscopes, 
which  they  presented  to  Prince  Maurice,  was,  in  the  year  1617,  in  the 
possession  of  Alkmaar,  who  then  resided  in  London  as  mathematician  to 
King  James  VI.  (See  Quekett  On  the  Microscope,  who  speaks  on  the 
authority  of  Sir  David  Brewster ;  see  also  Encyclopaedia  Britannica, 
"  Microscope.") 

It  does  not  require,  however,  a  compound  microscope  to  see  the  vessels 
in  question.    A  common  double  convex  spectacle  glass,  magnifying  only 

1  An  extract  from  an  address  delivered  before  the  College  of  Physicians  of  Phila- 
delphia, on  the  Tercentennial  Anniversary  of  Harvey's  birth,  April,  1878. 


1878.]        Forbes,  Harvey  and  the  Transit  of  the  Blood. 


139 


three  and  a  half  diameters,  gives  a  clear  view  of  "  the  capillary  vessels." 
With  such  a  glass  I  have  seen  them  in  the  cat.  Now  Harvey  saw  and 
described  the  "  punctum  saliens"  of  the  egg,  with  what  he  calls  "  perspi- 
cilli."  (Harveii  Opera,  Royal  College  of  Physicians'  edition,  1766,  page 
249.)  And  on  page  255  he  says  :  "  Clariori  tamen  luce,  perspicillis  que 
adhibitis,"  etc.  And  again,  page  267  :  "  Apparuit  (perspicillis  utenti)  in 
cervice,  vena?  ad  cerebrum  ascendentis  quasi  punctum  sanguineum." 

Harvey  was  in  the  habit  of  using  a  double  convex  lens.  He  describes 
one  of  manifestly  greater  power  than  those  used  in  common  spectacles  ;  for, 
on  page  338,  Harveii  Opera,  he  says  :  "  Quippe  radiis  solaribus  per  exi- 
guum  vitrum  transmissis,  et  in  conum  unitis,  igne  consestim  excitato." 

According  to  Boerhaave,  Swammerdam  had  recognized  the  blood  cor- 
puscle in  1658.  (See  Tyson  On  the  Cell  Doctrine,  page  16.)  He  must 
have  used  a  very  far  higher  power  than  enables  one  to  see  the  capillary 
vessels.    Now  Harvey  died  in  1657. 

The  opinion  held  and  expressed  by  the  above-mentioned  writers  is,  per- 
haps, predicated  on  that  which  we  find  in  the  life  of  Harvey,  written  by 
Doctors  Lawrence  and  Akenside,  and  published  together  with  his  works, 
under  the  auspices  and  by  the  authority  of  the  Royal  College  of  Physi- 
cians of  London,  in  1766.  This  work,  received  everywhere  now  as  autho- 
rity in  matters  concerning  Harvey,  has  these  words  on  page  xiii.,  Harveii 
Vita  :— 

"Duo  sunt  quidem,  ut  nequid  dissimulemus,  quibus  in  ratione  sanguis  circum- 

ferendi  explicanda  Harveium  defecisse  dolemus  Arteriaruin  etiam  minu- 

tarum  cum  venis  conjunetionem  primum  pernegavit ;  eandem  postea  invitus 
agnovisse  videtur,  ncc  tamen  rem  penitus  intellexisse."  And  on  page  xxix, 
"Concedit  arteriarum  propagines  minimas  inter  venarnm  tunicas  ita  posse  perre- 
pere,  ut  sanguis  in  venas  obhqua  tradatur  via,  quali  scilicet  ureteres  in  vesicam, 
et  ductus  eholedochus  in  intestinum  progrediuntur." 

I  take  leave  to  state,  with  the  greatest  diffidence,  that  a  contrary  opinion 
is  forced  upon  me,  after  an  extended  examination  of  Harvey's  works.  I 
take  leave  further  to  state,  that,  in  using  the  words  "  porositates  carnis," 
found  in  the  short  fourteenth  chapter  of  his  work,  De  Motu  Cordis,  etc., 
Rotterdam  editions  of  1648-1654  and  1661 ,  by  Arnold  Leers,  and  London 
edition  of  1661,  by  R.  Danielis;  and  in  his  second  letter  to  Riolanus,  Rot- 
terdam edition,  1661,  page  277,  where  Harvey  sums  up  his  views  on  the 
circulation,  and  traces  the  blood  through  the  arteries  into  the  "porositates," 
and  through  the  "  porositates"  into  the  veins,  and  through  the  veins  into 
the  heart,  Harvey  more  clearly  expresses  the  true  idea  of  the  transit  of 
the  blood  from  the  arteries  to  the  veins  than  is  now  conveyed  by  the 
expression  "  capillary  system  of  vessels."  The  word  "capillary"  relates 
only  to  the  hair-like  appearance  of  the  vessels,  while  "porositates"  trans- 
lated into  plain  English  would  be  "  ferries,"  and  relates  to  an  exact  func- 
tion, namely,  that  of  passing  the  blood  in  one  direction  only,  that  is,  from 
the  arteries  to  the  veins.    Now,  these  "ferries,"  the  ferry  vessels,  the 


140 


Forbes,  Harvey  and  the  Transit  of  the  Blood. 


[July 


ferry  system  of  vessels,  under  the  designation  of  "  porositates,"  Harvey 
points  out  and  dwells  upon.1 

In  this  fourteenth  chapter  Harvey  writes :  "Quod  sanguis,  per  pulmonee 
et  cor.  pulsu  ventriculorum  pertranseat,  et  in  universum  corpus  impellatur 
et  immittatur,  atque  in  venas  et  porositates  carnis  obrepat,  et  per  ipsas, 
undique  de  circumferentia  ad  centrum,  ab  exiguis  venis  in  majores 
remeet."  And  so  in  his  second  letter  to  Riolanus,  page  277,  Rotterdam, 
16G1  :  "  Nempe  de  auricula  dextra,  in  ventriculum,  de  ventriculo  per 
pulmones,  in  auriculam  sinistram,  inde  in  ventriculum  sinistrum  ef  in 
aortam,  omnesque  per  arterias  a  corde,  per  partium  porositates,  in  venas, 
et  per  venas,  ad  cordis  basin,  quam  celeriter  revertitur  sanguis."  Surely 
it  is  manifest  here  that  Harvey  places  a  tertium  quid  between  the  arteries 
on  the  one  side  and  the  veins  on  the  other  side.  He  calls  this  tertium 
quid  "  porositates  carnis"  and  "  partium  porositates."  He  meant  to  convey 
the  idea,  and  with  force  he  does  convey  the  idea,  that  the  "  porositates" 
take  the  blood  from  the  arteries,  and  through  the  parts,  and  into  the  veins. 
The  position  in  which  Harvey  places  the  word  "porositates"  and  its  de- 
rivation, and  its  being  used  in  the  plural  number,  all  these  considerations 
force  me  to  believe  that  he  used  it  knowingly  and  in  preference  to  any 
other  word,  such  as  ductus  or  capillares,  and  as  conveying  the  meaning 
that  the  blood  made  the  transit  from  the  arteries  t<»  the  veins,  and  in  one 
continuous  direction,  and  through  vessels  with  sides  to  them,  and  that  the 
blood  did  not  return  through  these  vessels,  namely,  through  the  porositates 
from  the  veins  back  into  the  arteries;  the  word  "capillares,"  or  ductus, 
embracing  no  such  meaning  as  that  a  return  of  the  blood  could  not  take 
place. 

First,  then,  in  regard  to  the  places  where  Harvey  uses  it.  We  find  he 
always  uses  it  in  speaking  of  the  passage  of  the  blood  from  the  arteries  to 
the  veins.2  Thus  in  chapter  VII.,  De  mortu  cordis,  Rotterdam,  1648, 
page  97,  "  Denique  clare  apparet  assertio  nostra,  continue  et  continenter 
sanguine  per  pulmonum  porositates  permeare,  de  dextro  in  ventriculum  si- 
nistrum," etc.  In  chapter  XI.  page  126  "  (vel  per  anastomosin  immediate, 
vel  mediate  per  carnis  porositates,  vel  utroque  modo),  transire  ab  arteriis 
in  venas."  In  the  Rotterdam  edition  of  1648,  the  two  letters  to  Riolanus 
do  not  appear,  having  been  written  at  a  later  period  ;  but  these  letters  are 
in  all  the  other  editions  to  which  I  have  alluded.  Now  these  letters  were 
written  by  Harvey  for  the  purpose  of  explaining  further  his  views  concern- 
ing the  circulation,  and  should  be  taken  as  of  equal  force  with  the  text. 

1  I  use  the  word  ferry,  Saxon  far  an,  to  pass,  in  its  original  sense,  that  in  which 
Spenser  uses  it,  "Him  to  ferry  over  that  deep  flood."  And  in  Shakespeare,  "The 
melancholy  flood,  with  that  grim  ferryman,  which  poets  write  of,  unto  the  kingdom 
of  perpetual  night"  (Richard  III.).  In  this  sense  the  word  does  not  comprehend  a 
return. 

-  One  exception  to  this  is  found  in  the  letter  to  Slegel,  and  will  be  mentioned  here- 
after, where,  by  the  departure,  Harvey  further  and  forcibly  gives  his  meaning. 


1878.]        Forbes,  Harvey  and  the  Transit  of  the  Blood.  141 


In  the  first  letter,  on  page  189,  we  find,  "Non  enim  tan  to  sanguine 
quantum  pars  quaeris  in  suis  arteriis,  venis  et  perositatibus  ubique  conti- 
net,  pro  alimento  utitur."  And  on  page  191,  "de  porositatibus  in  venu- 
las."  And  on  page  193,  "  Verum  amplius,  quod  ipse  sanguis  e  porositati- 
bus partium  regrediatur,"  etc.  And  on  page  268,  and  in  the  second  letter, 
"ut  exinde  fluxus  sanguinis  et  citatior  cnrsus,  per  arterias  exiles,  partium 
porositates,  venarumque  omnium  ramos,  necessario  fiat,  et  exinde  circula- 
tio." 

In  the  second  letter,  page  277,  we  have,  in  the  three  editions  I  have  men- 
tioned, "Omnesque  per  arterias  a  corde,  per  partium  porositates,  in  venas, 
et  per  venas,  ad  cordis  basin."  In  the  Royal  College  of  Physicians'  edition, 
page  138,  the  comma  so  emphatic  after  porositates,  and  also  that  one  after 
per  venas,  are  both  omitted.  Manifestly  by  so  doing  a  distinction,  an 
emphasis  is  done  away  with,  and  that,  too,  in  a  place  where  Harvey  was 
very  explicit.  Again  in  the  fourteenth  chapter  of  Harvey's  text,  and  in 
the  four  editions  I  have  alluded  to,  which  are  the  only  ones  I  have  access 
to,  but  which  in  this  chapter  are  uniform,  totidem  verbis  et  syllabis,  we 
have  "et  immittatur,  atque  in  venas  et  porositates  carnis  obrepat,  et  per 
ipsas,  undique  de  circumferentia  ad  centrum."  In  the  Royal  College  of 
Physicians'  edition  of  1766,  page  65,  we  find  that  the  comma  after  ipsas 
is  omitted,  and  that  the  word  "venas"  is  inserted  between  ipsas  and 
undique,  thereby  changing  the  meaning  of  Harvey.  Surely  these  are 
grave  errors,  made  by  the  learned  editors. 

To  show  both  the  onward  course  of  the  blood,  as  well  as  the  continuous 
walls  of  the  vessels  in  which  it  flowed,  Harvey  says  on  page  168  (Rotter- 
dam edition,  1661),  "Adeo  ut  ultimae  divisiones  capillares  arteriosae 
videantur  venae,  non  solum  constitutione,  sed  et  officio."  In  plain  English, 
"So  that  the  ultimate  capillary  divisions  of  the  arteries  appear  like  the 
veins,  not  merely  in  constitution,  but  also  in  function."  On  page  141  (Rot- 
terdam edition  1661),  "Nam  duos  contrarios  motus  in  capillari  propagine, 
chyli  sursum,  sanguinis  deorsum,  [in]convenienter  et  [im]probabiliter  fieri 
existimare  necesse  esset."  In  English,  "  Two  contrary  motions  in  the  capil- 
lary set,  chyle  going  one  way  and  blood  in  the  reverse  way,  can  not  well 
exist."  Harvey  well  knew  that  if  "  ductus"  and  "capillares"  would  permit 
possibly  of  a  current  in  one  way  and  then  in  the  reverse  way,  "porositates" 
would  exclude  such  an  idea.  He  knew  that  "porositates"  would  convey 
the  sense  its  derivation  entitles  it  to,  and  no  other.  The  word  has  a  Greek 
root,  with  a  Latin  termination,  in  the  feminine  gender.  The  root  is  Ttopo?, 
the  verb  is  ytfpaco,  to  drive  right  through,  to  pass  through,  to  traverse; 
rtfpaco  ft?  'AiSao,  Homer  says,  to  reach  the  abode  of  Hades.  This  word  is 
never  used  by  the  ancient  writers, ^o  far  as  I  know,  as  expressing  or  com- 
prehending any  idea  of  return. 

IIopos  the  noun  means  a  ferry,  a  passage.  Thus  iEschylus  speaks  of 
rtXorrwvos  rtopoj,  the  Stygian  ferry.    Pindar  sings  Biov  ytopoj,  the  stream  of 


142  Forbes,  Harvey  and  the  Transit  of  the  Blood.  [July 


life.  Pindar  and  iEschylus  speak  of  rtopoj  ''E?^,  the  Hellespont.  Pin- 
dar says  rfopoj  oxauavSpov,  the  Scamander.  iiopoj  Nf(,xov.  the  Nile.  There 
is  no  reflow,  no  reverse  tide  in  these  rivers;  they  flow  towards  the  sea. 

But  the  Euripus,  the  strait  on  the  east  of  Greece,  is  not  spoken  of  as 
rtopos  Evpirtov,  for  here  the  water  flows  through  and  then  reflows  at  stated 
intervals,  to  which  facts  the  ancients  often  allude.  These  old  writers  use 
the  word  rtopo$  with  exactness  and  precision  in  describing  the  continuous 
current  of  the  classic  rivers  of  antiquity;  so,  too,  Harvey,  with  great  taste 
and  meaning,  used  it  as  pointing  out  the  ever  onward  flow  of  the  tide  In- 
wished  to  demonstrate. 

Doctor  Robert  Willis  has  given  the  English  word  "pores"  as  the 
translation  of  Harvey's  Latin  word  " porositates,"  thus  for  "atque  in  venae 
et  porositates  carnis  obrepat,  et  per  ipsas,  undique  de  circumferentia  ad 
centrum,  ab  exiguis  venis  in  majores  remeet"  (see  fourteenth  chapter  Rot- 
terdam edition  1G61),  Willis  has,  "where  it  (the  blood)  makes  its  way 
into  the  veins  and  pores  of  the  flesh,  and  then  flows  by  the  veins  from  the 
circumference  on  every  side  to  the  centre,  from  the  lesser  to  the  greater 
veins."  (See  works  of  Harvey,  page  G8,  edition  of  Sydenham  Society.) 
And  for  "omnesque  per  arterias  corde,  per  partium  porositates  in  venas, 
et  per  venas,  ad  cordis  basin,  quam  celeriter  revertitur  sanguis"  (see  second 
letter  to  Riolanus,  page  277  Rotterdam  edition.  1661).  Willis  lias, 
"whence  by  the  arteries  at  large  through  the  pores  or  interstices  of  the 
tissues  into  the  veins,  and  by  the  veins  back  again  with  great  rapidity  to 
the  base  of  the  heart."  (See  works  of  Harvey,  page  138,  edition  of  the 
Sydenham  Society.) 

It  is  a  grave  error  to  attribute  to  the  word  "porositates"  a  loose  and 
secondary  sense,  such  as  belongs  to  the  English  word  "porosity."  This 
sense  would  not  likely  be  in  the  mind  of  those  who  used  the  word  when  it 
was  still  comparatively  a  recent  one,  and  when  its  derivation  was  still 
fresh  in  men's  minds,  and  when  the  Greek  authors  were  studied  by  phy- 
sicians and  all  other  scientific  writers.  It  is  an  error  to  suppose  the  word 
bore  a  mere  abstract  meaning  corresponding  to  its  abstract  form,  and  that 
it  indicated  no  more  than  a  mere  spongy  quality  in  the  parts  of  the  body 
through  which  the  blood  passed  from  the  arteries  to  the  veins.  In  Har- 
vey's age  the  idioms  of  the  best  Latin  writers  were  more  or  less  cultivated. 
The  fact,  too,  that  nouns  abstract  in  form  were  nearly  as  often  concrete 
in  sense  as  not,  shows  that  Harvey's  words  were  not  open  to  this  miscon- 
ception. For  it  was  well  known  that  Cicero  spoke  of  "magnas  clientelas" 
when  he  meant  "multos  clientes."  And  that  when  Tacitus  spoke  of  "fa- 
miliaritates  ejus"  in  the  case  of  Agricola,  he  meant  "familiares  ejus."  A 
multitude  of  such  cases  cjuM  be  alleged.  Especially  is  the  plural  use  of 
the  word  to  be  observed  as  decidedly  militating  against  the  notion  that  it 
was  used  by  Harvey  in  an  abstract  sense.  A  living  tongue  is  kept  supple 
by  daily  use ;  it  is  pliant ;  we  find  that  a  new  tinge  is  often  imparted  to 


1878.]        Forbes,  Harvey  and  the  Transit  of  the  Blood. 


143 


words  already  in  use,  and  by  assimilating  foreign  idioms  it  creates  new 
expressions  for  new  ideas.  The  dead  languages,  on  the  contrary,  are 
fixed,  having  been  cast  into  moulds  by  races  of  men  long  since  passed 
away ;  there  is  no  change  in  them. 

The  modern  word  "porosity"  is  alloyed — it  is  below  the  standard  of 
rtopoj.  But  because,  in  the  stream  of  to-day,  the  word  is  changed,  shall 
we  be  taught  that  the  distant  fountain  was  not  clear,  and  possessed  not 
the  virtue  once  attributed  to  it  by  Harvey?  And  used,  too,  as  it  was, 
by  him  for  many  reasons,  as  conveying  the  meaning  the  ancients  gave  it? 
Well  may  Coleridge  tell  us  that  "the  position  of  science  must  be  tried  in 
the  scales  of  the  jeweller;  not  like  the  mixed  commodities  of  the  market, 
on  the  weighbridge  of  common  opinion  and  vulgar  usage." 

The  further  assertion  of  Drs.  Lawrence  and  Aikenside,  namely,  that  Har- 
vey believed  "the  blood  to  be  delivered  in  an  oblique  way  into  the  veins, 
in  the  way  the  ureters  proceed  into  the  bladder,  and  the  common  chole- 
doch  duct  enters  the  intestine,"  is  an  error,  promulgated  under  the  sanc- 
tion of  the  Royal  College  of  Physicians  of  London  (unwittingly),  and  con- 
sequently received  and  believed,  and  has  done  more  to  cloud  the  view  of 
Harvey's  teaching  on  this  point  than  any  other  agency  of  which  I  am 
aware.  I  do  not  believe  that  such  a  view  could  be  taken  by  one  pro- 
perly construing  Harvey's  text,  and  taking,  singular  and  combined,  the 
meaning  and  intent  of  his  words.  The  passage  from  which  this  idea 
is  taken  by  the  authors  of  Harveii  Vita,  is  found  in  the  letter  of  Harvey 
to  his  friend  Paul  Slegel,  of  Hamburg,  and  is  dated  London,  April,  1651. 

I  have  seen  this  letter  of  Harvey  only  in  the  Royal  College  of  Physi- 
cians' edition  of  1766.  I  will  give  my  translation  of  the  words  of  Harvey 
as  found  in  his  letter  to  Slegel  in  this  edition;  beginning  on  page  617  at 
the  words  "  Qugeris  autem,"  and  ending  with  the  words  "adigere  queas." 

"But  you  will  ask  what  on  earth  is  this  contrivance?  what  on  earth  these 
ducts  ?  Certainly  the  little  arteries, ]  which  are  always  smaller,  shall  I  not  say 
twice  or  three  times,  than  the  veins  (which  they  accompany,  and  to  which  they 
gradually  approach),  and  at  length  are  lost  in  the  coats  of  the  veins:  so  that  1 
may  believe  that  the  blood  borne  forward  by  them  (the  little  arteries)  flows 
slowly  between  the  coats  of  the  veins  ;  and  the  same  happens  here,  which  becomes 
usual  at  the  junction  of  the  ureters  with  the  bladder,  and  the  biliary  pores  with 
the  intestine.  For  the  ureters  are  insinuated  into  the  bladder  obliquely  and  tor- 
tuously, and  not  in  the  nature  of  an  anastomosis  :  affording  now  and  then  a  way 
for  calculi  and  pus  and  blood  ;  so  that  by  them  you  can  easily  fill  the  bladder  with 
air  or  water ;  but  by  no  effort  can  anything  be  driven  from  the  bladder  back  into 
the  ureter." 

Xow  what  does  Harvey  mean  when  he  says  "the  same  happens  here 
which  becomes  usual  at  the  junction  of  the  ureters  with  the  bladder?" 
What  is  it  that  happens  there?  Harvey  goes  on  to  say  that  it  is  the 
prevention  of  the  return  of  water  from  the  bladder  to  the  ureters.  To 

1  In  using  the  word  "  arteriole"  in  this  place  instead  of  the  word  "  porositates"  as 
heretofore,  Harvey  increases  the  strength  of  his  position  in  pointing  out  the  continuous 
channels  in  which  the  blood  flows  in  passing  the  periphery. 


144  Forbes,  Harvey  and  the  Transit  of  the  Blood.  [July 

place  any  other  construction  or  sense  on  this  sentence  is  to  do  violence 
to  Harvey's  meaning;  the  whole  context  shows  this.  For  it  had  been 
asserted  by  Riolanus  and  others  that  there  was  an  anastomosis  by  con- 
junction, and  that  there  was  a  reflow  of  the  blood  from  the  veins  to  the 
arteries  after  the  manner  of  Euripus.  Slegel  calls  Harvey's  attention  to 
these  statements  of  Riolanus  (see  Harvey's  letter  to  Slegel).  Hence 
Harvey's  reply  to  Slegel,  in  which  he  explains  his  (Harvey's)  anasto- 
mosis, which  he  goes  on  to  say  is  not  by  conjunction,  "  per  copulam," 
but.  takes  place  by  means  of  "  arteriolar "  These  are  the  vessels  he  had 
in  his  publications  hitherto  called  "  porositates,"  thus  pointing  out  that 
in  vessels  with  continuous  coats,  that  is  walled  vessels,  the  blood  pro- 
gressed, journeyed  to  the  veins.  Then,  he  explains  that  there  were 
other  places  in  the  body  where  there  was  no  anastomosis,  yet  where 
water,  pus,  calculi,  etc.,  could  pass  in  one  way,  but  by  no  effort  could  any- 
thing be  forced  back  again ;  that  this  happened  where  the  ureters  enter 
the  bladder,  and  where  the  common  choledoch  duct  enters  the  intestine. 
Further  on  he  repeats  this  simile,  and  refers  to  his  letter  to  Riolanus. 
In  chapter  xiii.  of  his  text  Harvey  had  demonstrated  that  the  valves  in 
the  veins  prevented  any  return  of  the  blood. 

To  sum  up,  then,  from  the  testimony,  we  arc  forced  to  the  belief  that  Har- 
vey did  have  the  means  of  seeing,  and  that  he  did  know,  and  was  the  first 
to  point  out,  that  "order  of  sanguiferous  vessels  ending  by  uninterrupted 
continuity"  in  the  arteries  at  one  extremity,  and  in  the  veins  at  the  other 
extremity;  and  that  under  the  title  of  "porositates"  he  gave  "the  exact 
channels,"  the  ferry  system  of  vessels  by  which  the  blood  passes  from  the 
arteries  into  the  veins.    This  belongs  to  Harvey,  and  to  Harvey  alone.1 

From  this  view,  then,  of  Harvey's  writings,  I  ask  the  question,  and  I 
hope  at  some  future  time  it  will  be  answered,  have  not  these  great  authori- 
ties— Willis,  Huxley,  and  the  Royal  College  of  Physicians  of  London — 
done  their  illustrious  countryman,  Harvey,  great  injustice?  For  "have 
they  been  sufficiently  circumspect  ?  Have  they  sufficiently  inquired  into 
Harvey's  meaning?  Have  they  quoted  his  words  faithfully?"  If  they 
have  not,  in  what  does  their  position  before  the  world  differ  from  that  of 
Doctor  Geynes  (see  Dr.  Sieveking's  Harveian  oration,  Lancet,  vol.  L, 
1862),  who,  according  to  Doctor  Munk,  in  his  role  of  the  College  of  Phy- 
sicians, was  brought  by  the  Fellows  to  the  bar  of  the  College  for  venturing 
to  question  the  authority  of  Galen,  and  made  to  recant  or  go  to  prison? 

Let  us  indulge  the  hope  that  these  gentlemen,  like  Dr.  Geynes.  will 
recant.  Let  us  believe  that  the  Royal  College  of  Physicians  of  London, 
the  special  beneficiary  of  Harvey's  trust,  will  not  sanction  the  keeping  of 
Harvey's  name  in  a  relation  so  false  as  that  in  which  it  has  been  placed 

1  Malpighi  afterwards  further  elaborated  the  same  subject.  Malpighi,  Opera. 
London,  1686. 


1878.] 


Hold  ex.  Is  Consumption  Contagious? 


145 


in  regard  to  the  transit  of  the  blood  from  the  arteries  to  the  veins.  Let 
us  hope  the  College  will  give  the  world  a  new  and  revised  edition  of  his  „ 
lite  and  works,  and,  as  this  coin  bears  the  image  and  superscription  of  the 
King,  "Render  unto  Caesar  the  tilings  that  are  Caesar's." 
Philadelphia,  Xo.  1405  Locust  Street. 


Article  XV. 

Is  Consumption  Contagious?  By  Edgar  Holden,  M.D.,  Ph.D.,  Presi- 
dent of  the  Medical  Department  of  the  Mutual  Benefit  Life  Insurance  Com- 
pany. Newark.  New  Jersey.1 

MoRGAGNi  quotes  from  ancient  writers  the  evidences  in  favour  of  his 
own  convictions  that  consumption  should  still,  as  before  his  day,  be  con- 
sidered contagious.  Laennec  believed  himself  to  have  been  inoculated 
with  tubercle  during  a  post-mortem  examination.  Andral  boldly  asserted 
his  convictions  in  favour  of  the  same  doctrine  ;  and  Beale,  in  his  work  on 
"  Disease  Germs,"  p.  152,  uses  the  following  language  : — 

"  Living  tubercle  germs  will  not  be  considered  as  very  closely  related  to  the 
contagious  particles  which  are  the  active  agents  in  the  propagation  of  contagious 
fevers.  There  is.  however,  reason  to  think  that  particles  of  living  growing  tu- 
bercle exist  sufficiently  minute  to  be  supported  by  the  atmosphere  and  carried 
long  distances,  while  there  are  many  facts  considered  by  many  sufficiently  con- 
clusive to  justify  the  opinion  that  tubercular  disease  of  the  lungs  is  at  least  in  some 
instances  contagious." 

The  latter  guarded  statement  aptly  expresses  the  views  of  many  who 
believe  in  the  doctrine,  but  feel  that  it  is  not  yet  proved.  To  simplify 
our  study  of  the  subject,  it  may  be  well  to  say  that  the  question  we  now 
propose  is,  whether  it  is  without  direct  inoculation  communicable  by 
one  person  to  another.  The  researches  of  Villemin2  on  the  inocula- 
bility  of  tubercle,  and  the  subsequent  investigations  by  Andrew  Clark, 
Fox,3  Sanderson,  and  others,  which  showed  that  any  septic  material  when 
inoculated  may  develop  a  disease  of  the  glandular  system  akin  to  phthisis, 
are  doubtless  familiar.  The  real  point  being  whether  any  septic  material 
is  eliminated  from  the  body  of  a  person  suffering  from  necrobiotic  changes 
in  the  lungs,  which,  floating  in  the  air  or  transferred  by  contact,  may 
develop  the  same  affection  in  another  person.  TTe  should  still  further 
simplify  our  inquiry  if  we  use  the  words  consumption,  phthisis,  and  tuber- 
culosis as  synonymous,  although,  personally,  I  adopt  without  hesitation 
the  modern  views  of  a  complete  and  radical  difference  between  phthisis 

1  At  the  time  of  the  appearance  of  the  interesting  article  by  Dr.  Webb  in  the  last 
number  of  this  Journal,  this  article  was  almost  complete. 
3  Edinburgh  Med.  Jour.,  Feb.  1887,  p.  756.  3  Pamphlet,  1868.  London. 

No.  CLI — July  1878.  10 


146 


Hold  ex,  Is  Consumption  Contagious? 


[July 


and  tuberculosis.  For  our  present  purpose,  however,  the  distinction  is 
unimportant,  as  if  contagious  at  all  it  is  chiefly  so  in  the  later  stages, 
when  the  one  may  have  merged  into  the  other,  and  the  latest  stages,  fol- 
lowed by  death,  will  alone  be  drawn  upon  for  illustration.  The  subject 
has  received  attention  from  many  writers,  and  one  Dr.  Windrif,  of  Cftesel 
(Sydenham  Year  Booh,  1869,  p.  126),  quotes  some  interesting  examples, 
of  which  the  following  are  worthy  of  record  : — 

"  A  medical  student  at  Berlin  was  found  to  have  a  rapidly  developing  phthisis, 
and  went  home  to  die.  A  foster-brother,  in  whose  lineage  no  trace  of  consump- 
tion could  be  found,  took  his  clothing,  and  continued  to  wear  it  after  his  brother's 
death.  He  began  to  have  a  slight  cough,  consolidation,  softening,  emaciation, 
profuse  expectoration,  and  death  followed  within  one  year. 

"A  woman,  a?t.  35,  had  consumption.  During  her  illness  a  twin  sister  of 
robust  health  began  wearing  her  garments.  She  died  just  six  months  after  the 
victim  whose  clothing  she  was  using. 

"  A  mother  died  shortly  after  delivery,  and  the  monthly  nurse  continued  with 
her  from  the  delivery  till  her  death.  In  her  own  family,  on  both  sides,  no  case 
of  like  disease  had  occurred.    She,  however,  died  within  the  year  following." 

Many  other  instances  of  like  character,  and  particularly  of  husbands 
and  wives,  were  given,  and  attention  was  called  to  the  peculiar  exhalation 
from  the  body  of  a  consumptive  in  the  third  stage  of  the  disease. 

The  prevalence  of  popular  prejudice  on  this  question  is  noticeable  in 
many  countries,  and,  perhaps,  in  none  more  so  than  in  Spain,  France, 
and  Italy.  The  servants  are  fearful  of  the  washing  of  the  linen  ;  they 
dread  the  sweepings  of  the  rooms;  and  the  landlords,  after  a  death  in  their 
hotels,  exact  exorbitant  sums  for  the  use  of  rooms  where  victims  have 
spent  their  final  hours,  to  enable  them  to  burn  everything  which  could 
possibly  preserve  the  elements  of  contagion.  Carpets,  bedding,  and  even 
the  wooden  chairs  and  bedsteads  are  sometimes  so  destroyed  (if  the  state- 
ments of  the  landlords  themselves  can  be  accepted  as  evidence). 

It  is  somewhat  singular  that  the  firmness  of  conviction  in  some  minds 
is  as  strong  as  the  opposite  belief  of  others ;  yet  where  doubt  must  of  ne- 
cessity exist,  it  is  less  surprising  than  that  two  opinions  should  be  possible 
regarding  so  contagious  a  disease  as  scarlet  fever.  I  have  heard  a  phy- 
sician of  considerably  more  experience  than  judgment  gravely  argue  that 
this  latter  disease  was  neither  infectious  nor  contagious. 

To  decide  whether  consumption  is  communicable  it  is  not  necessary,  it 
seems  to  me,  to  find  any  specific  microzymes  which  may  have  emanated  from 
the  body,  and  so  have  infected  the  atmosphere,  or  passed  by  contact  so  as 
to  render  their  absorption  certain  to  develop  kindred  disease.  AVe  have 
demonstrated  the  proposition  without  this  if  it  can  be  shown  that  septic 
material  of  any  character  is  cast  into  the  atmosphere  or  presented  to  a 
healthy  surface,  and  so  produces  disease  akin  to  itself.  To  take  any  differ- 
ent position  involves  the  question  as  to  whether  consumption  is  a  zymotic 
disease,  a  point  probably  settled  by  the  profession  after  the  somewhat 
singular  pamphlet  left  with  Paget,  by  Dr.  Budd,  some  years  since,  to  be 
opened  only  under  specific  contingencies.    Xor  do  we  need  the  researches 


1878.] 


Hold  en,  Is  Consumption  Contagious? 


147 


that  followed  Villemin's  experiments  on  the  inoculability  of  tubercle;  and 
the  announcement  that  any  animal  material  in  a  state  of  decomposition 
Mould  develop  the  same  affections  of  the  lymphatic  system  as  those  that 
followed  the  introduction  of  the  tuberculous  matter,  as  groundwork  on 
which  to  build  our  proposition. 

"  Is  consumption  communicable  by  the  exhalations  of  the  body  excre- 
tory or  secretory  ?"  The  affirmative  answer  to  either  of  the  two  following 
questions  ought  to  answer  the  question  at  issue  : — 

1.  Do  practical  experience  and  observation  seem  to  show  that  it  is? 

2.  Admitting  errors  of  clinical  deductions,  can  the  products  of  retro- 
grade metamorphosis  of  tissue,  as  thrown  off  by  the  lungs  and  skin  in 
consumption,  produce  in  a  healthy  person  the  same,  or  other,  or  any  dis- 
ease ?  In  other  words,  and  simply,  Can  it  and  does  it  produce  similar  or 
any  disease? 

With  regard  to  the  first  of  these  questions  which  rhetorically  should 
precede  the  other,  startling  examples  at  times  occur  when  the  evidence 
seems  almost  conclusive  ;  but  the  caution  that  must  of  necessity  invest  all 
the  deductions  from  medical  observation,  urges  the  old  and  sarcastic  2Jost 
hoc  non  propter,  and  the  question  is  again  unanswered. 

So  many  striking  instances  have  occurred  in  my  own  experience  as  to 
induce  an  extended  inquiry  concerning  the  opinions  of  reliable  physicians 
throughout  the  country;  and  with  the  assistance  of  several  confreres  this 
has  been  done  by  circulars  addressed  to  every  county,  and  to  most,  if  not 
all,  the  important  towns  throughout  the  United  States.  The  physicians 
addressed  have  been  those  only  who  were  known  to  be  the  best  in  their 
respective  localities,  and  their  replies  have  hence  been  considered  entitled 
to  respect  and  confidence. 

These  number  two  hundred  and  fifty,  being  about  one-half  of  those 
addressed.  The  result  shows  an  almost  equal  division  of  opinion.  It 
should,  however,  be  noted  that  those  whose  attention  has  been  much  given 
to  pulmonary  disease  quite  frequently  incline  to  the  belief  in  contagion ; 
while  those,  however  eminent  as  scientific  men,  whose  tastes  lead  them  to 
other  departments  of  medical  science,  adopt  the  now  most  generally  ac- 
cepted doctrine  of  non-contagion. 

Out  of  the  whole  number  whose  views  are  recorded  I  have  selected 
twenty-eight  as  standing  above  their  fellow  practitioners,  and  of  these 
eleven  believe  in  contagion,  twelve  do  not,  and  jive  are  not  positive. 

The  general  summary  of  view  is  as  follows  : — 

One  hundred  and  twenty-six  answer  aye.  Seventy-three  of  these  speak 
emphatically,  and  give  cases  in  illustration. 

Seventy-four  answer  no.  Fifty  are  in  doubt,  or  have  had  too  little  ex- 
perience in  pulmonary  disorders. 

There  are  therefore  one  hundred  and  twenty-six  in  favour,  and  the  re- 
mainder positively  or  doubtfully  against  the  theory.    Perhaps  to  divide 


148 


Hold  ex.  Is  Consumption  Contagious? 


[Julr 


the  doubtful  would  be  more  fair,  and  to  say  that  ninety-nine  are  against 
and  one  hundred  and  fifty-one  in  favour  of  it.  In  any  case  the  difference 
is  less  than  was  anticipated,  and  may  be  considered  a  fair  view  of  the  pro- 
fessional opinion  of  this  country  on  the  subject. 

The  replies  from  different  States  are  summarized  as  follows,  and  it  will 
be  observed  that  the  States  to  which  consumption  is  not  indigenous  are 
omitted.  The  reason  of  this  is  that  in  such  States  as  Minnesota  and  Florida, 
for  example,  there  seeme  I  danger  of  obtaining  facts  without  a  fair  and 
proper  knowledge  of  collateral  history  and  family  tendencies,  a  matter  of 
extreme  importance. 


State. 

replies. 

Wo. 

Xot  observed. 

Pennsylvania  .... 

47 

29 

u 

3 

Missouri  ..... 

23 

7 

7 

9 

Iowa  ..... 

23 

9 

5 

9 

State. 

Replies. 

Aye. 

5o. 

Kot  sure. 

Connecticut  .... 

4 

•) 

0 

2 

Maryland  and  l>ist.  of  Columbia 

3 

•> 

1 

0 

Kentucky  .... 

10 

4 

1 

5 

Wisecnsin  .... 

10 

4 

5 

1 

New  Jersey  .... 

4 

1 

2 

Illinois  

32 

17 

11 

4 

Ohio  

32 

20 

9 

3 

Maine  

4 

1 

2 

New  York  .... 

12 

9 

6 

Michigan  .... 

5 

1 

Tennessee  .... 

14 

10 

3 

1 

Uncertain  .... 

o 

As  the  testimony  of  observation  and  experience  is  a  positive  testimonv. 
and  that  of  the  doubtful  non-observer  is  an  assertion  at  the  best  but  nega- 
tive, some  of  the  former  can  with  benefit  be  submitted. 

The  following  extracts  have  been  selected  somewhat  at  random,  although 
but  a  small  part  of  the  whole. 

Cases  in  the  same  family  adduced  in  evidence  are  not  given  ;  as  being 
liable  to  other  plausible  interpretation,  e.  g..  on  the  ground  of  heredity. 

On  the  same  principle  those  of  near  relatives  are  also  excluded.  (One 
or  two  exceptions,  however,  will  be  observed. ) 

Dr.  McReynolds.  of  Clarksville.  Tenn..  savs  :  TThile  not  positive,  my 
practice  has  presented  instances  of  certain  strong  and  seemingly  healthful 
men  having  no  traceable  hereditary  tendencies,  who.  after  nursing  their 
wives  through  long  and  tedious  illness,  have  in  a  few  years  themselves  suc- 
cumbed to  a  similar  sickness." 

Dr.  Todd,  of  Indianapolis.  Ind..  says  :  ••  My  observations  during  a 
period  of  twenty-four  years'  active  practice  long  ago  convinced  me  that 
such  was  the  case  (i.  e..  the  disease  is  infectious ).  I  have  known  a  number 
of  instances  where  parties  with  no  hereditary  tendencies  or  predisposition 
have,  after  long  and  intimate  association  with  those  affected,  themselves 
fallen  victims." 


1878.] 


Hold  en,  Is  Consumption  Contagious? 


149 


Scores  of  replies  are  indefinite ;  thus  Dr.  Fitzgibbon,  of  Washington, 
Ind.,  says  :  "  A  remarkably  healthy  woman,  who  had  no  hereditary  predis- 
position whatever  in  her  family,  contracted  consumption  from  her  husband 
and  died.    She  had  several  children,  all  delicate." 

More  satisfactory  are  the  following :  Dr.  W.  K.  Mavity,  of  Kokomo, 
Ind.,  says :  "  Mr.  H.  married  Miss  F.,  who  was  apparently  healthy  in  every 
respect,  and  free  from  any  known  hereditary  disease.  In  three  years  Mr. 
H.  was  confined  to  his  house  and  bed  with  consumption,  lingered  a  year 
and  died.  In  one  year  more  the  wife,  who  had  borne  a  child  and  dili- 
gently watched  and  nursed  her  husband,  was  taken  with  the  same  disease, 
with  less  marked  symptoms,  however,  at  the  onset,  save  a  persistent,  dry, 
hacking  cough,  and  in  less  than  two  years  died." 

Dr.  M.  Hoge,  of  Cambridge,  Ohio,  gives  cases  of  which  the  following  is 
an  example.  "  A  gentleman  of  robust  health,  and  constitution  free  from 
hereditary  taint,  set.  40,  had  been  married  to  a  delicate  consumptive  lady. 
For  the  last  two  years  of  their  married  life  she  was  much  confined  to  her 
room.  Her  husband  spent  much  time  with  her.  Toward  the  latter  part 
of  her  illness  her  health  declined,  and  in  two  years  after  her  death  he  also 
died  of  undoubted  phthisis." 

Dr.  G.  A.  Way,  of  Caldwell,  Ohio,  gives  three  instances,  in  all  of  which 
the  wife  or  husband  followed  their  deceased  partners  in  about  a  year,  there 
being  in  neither  of  the  cases  any  predisposing  family  taint. 

Dr.  Otis,  of  New  Philadelphia,  Ohio,  gives  the  following  case  now  under 
observation:  "A  lady  lost  her  husband  from  consumption  fifteen  years 
ago.  During  all  this  time  she  had  suffered  at  intervals  from  phthisical 
symptoms,  although  never  prior  to  the  illness  of  her  husband,  and  there  had 
never  existed  a  case  of  consumption  in  her  family.  Eight  years  ago  she 
married  a  second  time,  and  gave  birth  to  a  child  of  marked  consumptive 
diathesis,  although  its  father  was  strong  and  sound." 

Dr.  David  Rush,  of  Celina,  Ohio,  details  several  instances  of  the  appa- 
rent transmission  from  wife  to  husband  or  husband  to  wife,  and  one  of  a 
student  who,  previously  healthy  and  of  healthy  stock,  appeared  to  contract 
the  disease  from  a  comrade  with  whom  he  was  intimate,  rooming,  eating, 
and  working  together. 

Dr.  H.  S.  Smith,  of  Blandville,  Kentucky,  gives  several  cases,  chiefly  of 
husbands  and  wives,  and  one  in  which  the  victim  was  one  of  a  large  family 
of  brothers  and  sisters  (eight),  none  of  whom  were  of  even  delicate  habit. 

Dr.  E.  D.  Kittoe,  of  Galena,  111.,  makes  the  following  interesting  state- 
ment: u  I  have  frequently  noticed  the  occurrence  of  death  from  this  cause 
in  persons  who  had  cared  for  and  nursed  friends  who  had  died  of  consump- 
tion, but  who  before  doing  so  showed  no  tendency  to  it,  and  in  whom  there 
was  no  evidence  of  hereditary  taint ;  for  a  marked  case  see  the  following. 
The  late  General  J.  A.  R.  was  born  and  brought  up  near  this  city ;  his 
parents  are  both  living  at  this  time,  remarkably  robust  and  healthy ;  no  case 
of  tubercular  disease  has  ever  been  known  to  have  affected  the  ancestors 
of  either  father  or  mother. 

"  General  R.  was  a  remarkably  strong  and  vigorous  man,  both  mentally 
and  physically,  prior  to  his  marriage.  He  married  a  Miss  S.  from  Utica. 
By  this  union  he  had  three  children.  Miss  S.  came  of  consumptive  family, 
and  the  disease  in  the  wife  developed  soon  after  marriage.  The  General 
was  a  very  kind  and  attentive  husband  and  nurse,  and  gave  himself  up 
almost  entirely  to  that  duty,  staying  often  in  a  close  room  with  her  up  to 
her  death.  After  this,  he  was  almost  at  once  placed  on  the  staff  of  General 


150 


H olden,  Is  Consumption  Contagious? 


[July 


Grant.  I  observed  soon  that  he  had  a  slight  cough,  and  in  the  summer 
of  1863,  after  the  siege  of  Corinth,  he  had  fistula  in  ano,  for  which  the 
usual  operation  was  performed.  He  continued  to  have  cough  from  that 
time  forward.  On  the  occasion  of  General  Grant  being  ordered  to  super- 
sede Rosencranz  at  Chattanooga,  in  crossing  Waldron  bridge,  we  were 
exposed  to  a  heavy  rain  all  day,  and  on  arriving  at  Chattanooga  the  Gene- 
ral's cough  became  very  bad,  with  sanio-purulent  expectoration.  "When 
he  left  with  Grant  for  the  Potomac,  he  was  very  thin,  but  his  indomitable 
energy  kept  him  up.  At  the  close  of  the  war,  he  was  in  a  well-dehned 
tubercular  condition,  and  gradually  gave  way  till  he  died." 

A  singular  fact  is  here  discovered.  This  history  of  General  R.  is,  by 
a  remarkable  coincidence,  taken  up  by  another  physician,  from  another 
State,  and  entirely  without  the  knowledge  the  one  of  the  other,  and  is  thus 
elaborated  by  the  latter  : — 

Dr.  Bennett,  of  Danbury,  Conn.,  says:  "About  three  years  before  he 
(General  R.)  died,  he  again  married — a  Miss  H.,  none  of  whose  family 
have  any  tendency  to  consumption.  He  died  of  consumption.  The  second 
wife  also  died,  in  a  year  or  eighteen  months  after,  of  the  same  disease.  She 
bore  him  two  children  of  feeble  constitution,  which  died  in  a  day  or  two 
after  birth.  The  family  believe  that  the  disease  was  transmitted  from  the 
first  wife  to  the  husband,  and  by  him  to  the  second  wife." 

Dr.  J.  N.  Barnes,  of  Decatur,  111.,  gives  the  following  succinct  account 
of  a  case:  "  A  married  man,  after  a  few  years'  sickness,  died  with  heredi- 
tary consumption.  A  few  months  after  his  death,  his  wife,  who  had  nursed 
him,  although  previously  healthy  and  vigorous,  and  with  nothing  heredi- 
tary as  far  back  as  her  lineage  could  be  traced,  and  without  having  taken 
cold  or  other  apparent  exciting  cause,  except  exhaustion  from  care  and 
nursing,  took  consumption  and  died." 

Dr.  G.  W.  Jones,  of  Danville,  111.,  gives  a  considerable  number  of  in- 
stances, of  which  the  following  are  the  most  interesting: — 

The  husband  of  Mrs.  C.  A.  L.  died  of  phthisis.  For  three  or  four 
years  after  this  she  suffered  from  all  the  symptoms  of  the  first  and  second 
stage.  She  has  fully  recovered,  and  by  a  second  husband  borne  a  large 
family  of  fine  healthy  children.    The  disease  is  not  in  her  ancestry  at  all. 

Mrs.  C.  M.,  of  very  fine  family  record.  Husband  died  of  phthisis  in 
May  ;  her  attention  had  been  unremitting.  She  died  of  phthisis  the  fol- 
lowing April,  and  is  the  only  one  of  her  family  who  ever  had  the  disease. 

Mr.  ,  of  very  fine  record ;  wife  died  of  phthisis  four  or  five  years 

since.  He  presents  now  the  physical  evidences  of  the  disorder,  and 
travels  north  or  south  with  the  seasons.  He  was  his  wife's  constant  com- 
panion and  nurse. 

Many  observers  make  the  statement  that  in  no  instance  have  they  seen 
the  disease  communicated  from  wife  to  husband,  but  only  the  reverse,  and 
some  boldly  assert  that  through  conception  and  the  rearing  of  children 
alone  is  it  conveyed. 

Dr.  W.  M.  Chambers,  of  Charlestown,  111.,  gives  three  such  instances, 
and  one  where  the  surviving  son  of  such  conception  himself  married,  and 
appeared  to  convey  the  disease  to  his  wife,  whose  family  was  free  from 
consumptive  taint.    Other  observers,  however,  give  cases  where  the  hus- 


1878.] 


Hold  en,  Is  Consumption  Contagious? 


151 


band  appeal's  to  have  become  affected  by  the  marriage.  Dr.  B.,  of  N.  J., 
gives  such  an  instance  in  a  young  man  of  twenty-four,  who  was  without 
suspicion  of  consumptive  taint,  and  from  a  family  equally  free. 

A  few  cases  are  herewith  tabulated,  as  of  similar  character  and  interest. 
First,  those  like  that  of  General  J.  A.  R.,  given  above.  Thus  Dr.  J.  W. 
Hoff,  of  Pomeroy,  Ohio,  says  : — 

k-  Recently  I  knew  a  wife  to  take  and  die  of  consumption  ;  in  one  year  it 
was  fully  developed  in  her  husband.  He  married,  however,  and  died 
within  a  year  thereafter.  His  second  wife  followed  him  with  the  same 
disease,  and  also  their  babe.  In  the  past  thirty  years,  I  have  seen  many 
undoubted  instances  of  its  infectious  character,  and,  I  believe,  the  female 
will  contract  it  the  more  readily  from  the  male  than  vice  versa." 

Dr.  L.  McDowell,  of  Flemingsburg,  Ky.,  says  he  knew  a  man  who  had 
all  the  external  appearances  of  a  tuberculous  diathesis,  who  married  a 
healthy  girl  of  eighteen.  In  three  years  (after  the  birth  of  her  second 
child)  she  died  of  tuberculosis.  He  married  in  a  year  and  a  half  again, 
and  to  an  exceedingly  robust  woman,  of  a  family  without  taint.  In  less 
than  two  years  she  died  of  unmistakable  pulmonary  consumption.  The 
third  time  he  married  a  healthy  woman.  He  himself  died  in  twelve 
months  after  his  third  marriage  with  consumption,  and  his  widow  followed 
him  in  six  months  with  the  same  disease. 

Dr.  W.  C.  Bennett,  of  Danbury,  Conn.,  says :  "Mr.  H.  D.,  of  Bethel, 
was  healthy  and  of  healthy  family,  with  no  known  tendency  to  consump- 
tion. His  wife  died  of  the  disease.  He  married  again,  and  soon  afterward 
sickened  and  died  of  the  same.  The  second  wife  then  sickened  and  died 
of  consumption.  They  all  lived  and  died  in  the  same  house,  in  an  appa- 
rently healthy  location,  and  probably  used  the  same  bedding.  I  doubt  if 
the  second  wife  bore  him  children  ;  but  of  the  two  children  of  his  first 
wife  one  is  dead  of  consumption,  and  the  other  far  advanced  in  the  same 
disease." 

Dr.  A.  F.  Gillette,  of  Lyons,  N.  Y.,  gives  the  following  interesting 
history  of  a  family  by  the  name  of  Root.  There  were  five  sons  and  three 
daughters. 

Joel  died  of  pulmonary  disease  ;  wife  now  living. 

Tiler  died  of  pulmonary  disease,  but  married  after  he  became  ill,  and 
his  wife,  although  without  family  tendencies  to  the  disease,  died  of  it.  He 
married  again,  and  his  second  wife  died  in  the  same  manner,  she  being 
the  only  case  in  her  father's  family. 

Darwin  died  of  pulmonary  disease ;  his  wife  followed  him  with  same 
disease,  and  her  family  also  was  free  from  taint. 

Frederick  now  living,  but  has  laryngeal  trouble. 

Andrew  died  of  acute  bowel  difficulty. 

Mary  and  Elmira  died  of  pulmonary  disease. 

Eveline  married,  died  of  consumption,  and  was  followed  by  her  hus- 
band, whose  family  had  never  shown  hereditary  difficulty,  being  strong, 
long-lived,  and  of  a  robust  race. 

The  following  remarks  are  interesting,  as  bearing  upon  those  cases  not 
related  by  marriage  or  relationship. 

Dr.  Inglis,  of  Detroit,  an  acute  observer,  after  saying  that  he  had  not 


152 


Holden,  Is  Consumption  Contagious? 


[July 


seen  indubitable  evidence  of  contagion  in  his  practice,  continues,  "  I  have, 
however,  in  the  wards  of  Prof.  Frantzel  in  the  Vienna  General  Hospital, 
seen  such  striking  cases  explicable  in  no  other  way  as  to  make  me  believe 
that  the  disease  is  communicable  when  persons  are  confined  to  constant 
inhalation  of  the  breath  of  consumptives  without  sufficient  out-door  air  and 
exercise." 

Dr.  W.  H.  Webb,  of  Philadelphia,  says  :  "  In  January,  1874,  I  attended 
a  lady  who  had  phthisis;  her  family,  which  was  long-lived,  presented  no 
history  of  that  disease.  She  had  been  in  constant  attendance  upon  a  lady 
friend  during  the  winter  and  spring  of  1873,  who  died  of  consumption  in 
May  of  that  year.    My  patient  died  in  March,  1874." 

Many  of  the  reports  are  non-committal,  and  yet  of  interest. 

Dr.  H.  J.  Rice,  of  Rockville,  Ind.,  says :  "  I  have  seen  no  cases  free  from 
doubt.  In  the  case  of  husbands  and  wives  I  have  universally  observed 
that  where  one  of  the  parties  suffered  with  phthisis,  the  other  was  in  a 
condition  of  impaired  health,  with  decided  symptoms  of  the  disease.  The 
nutrition  of  the  system  is  diminished,  the  appetite  fails,  there  is  cough, 
etc.,  symptoms  which  usually  pass  off  upon  the  death  or  recovery  of  the 
party  first  affected."  He  then  proceeds  to  speak  of  the  effects  of  watch- 
ing, anxiety,  etc.,  as  possibly  the  causes  of  this  impairment  of  health. 

Dr.  J.  W.  Randall,  of  Albion,  N.  Y.,  cautiously  speaks  of  the  influence 
of  an  advanced  stage  of  the  disease  on  those  broken  by  long  watching  and 
anxiety,  but  gives  the  following  instances  confirmatory  of  the  contagion 
theory. 

Two  men  of  healthy  family,  and  free  from  any  records  of  consumption, 
married  into  consumptive  families  ;  in  both  instances  the  wives  died,  and 
the  parties,  with  some  of  the  children,  have  followed  within  a  brief  period. 

Two  other  instances  also,  the  one  of  a  rugged  and  healthy  woman,  and 
the  other,  a  robust  man,  both  married  consumptive  companions.  Both 
the  latter  died  ;  but  the  former,  after  varying  experiences  from  cough, 
hemorrhages,  etc.,  had  enough  vitality  remaining  to  rally,  and  regain  very 
good  health. 

Dr.  H.  P.  Clark,  of  Ashland,  O.,  after  giving  instances  of  apparent  con- 
tagion and  cases  of  recovery  where  a  strong  constitution  enabled  the  par- 
ties to  survive  the  period  even  of  softening  and  cavity,  proceeds  to  question 
the  accuracy  of  the  observation,  and  to  doubt  whether  other  influence  than 
contagion  may  not  have  predominated. 

The  instances  adduced  of  wives  contracting  consumption  from  their  hus- 
bands, when  the  careful  investigation  of  family  history  showed  a  remark- 
able freedom  from  hereditary  taint,  and  the  same  of  husbands  contracting 
the  disease  from  the  wives,  are  too  numerous  to  mention. 

Dr.  C.  E.  Beardsley,  of  Ottawa,  0.,  gives  several  cases  of  interest. 

Dr.  G.  E.  Corbin,  of  St.  John's,  Mich.,  gives  also  several  as  an  emphatic 
evidence  of  his  convictions. 

Dr.  H.  V.  Passage,  of  Peru,  Ind.,  gives  an  interesting  case  of  a  rugged, 


1878.] 


Hold  en,  Is  Consumption  Contagious? 


153 


healthful  woman,  whose  consumptive  husband  regained  his  own  health, 
and  seemed  to  transfer  his  disease  to  her. 

Dr.  H.  Brubaker,  of  Somerset,  Penn.,  gives  three  instances,  in  all  of 
which' the  second  victim  followed  the  first  within  a  year,  there  being  no 
similar  disease  in  the  families  of  the  latter. 

Equally  numerous  also  are  the  cases  where  the  disease  once  started  in  a 
family  appeared  to  affect  one  member  after  the  other,  and  although  such 
cases  at  once  suggest  the  development  of  a  diathesis  under  circumstances 
common  to  all  the  family,  and  therefore  not  suggestive  of  contagion,  it  is 
by  no  means  certain  that  they  are  not  valuable  in  answering  the  question 
propounded. 

Dr.  D.  W.  Crouse,  of  "Waterloo,  Iowa,  for  example,  writes  as  follows  : 

"In  a  family  where  three  daughters  were  much  attached  to  each  other, 
one  who  had  been  some  time  absent  came  home  to  be  nursed  by  her  sisters, 
she  having  consumption.  One  of  them  showed  the  evidences  of  the  disease 
at  about  the  time  of  the  other's  death,  and  died  within  a  year  thereafter. 
The  second  sister,  who  then  became  nurse,  contracted  the  disease,  and  is 
now  rapidly  railing." 

"  The  wife  of  a  lawyer  of  my  acquaintance  came  home  to  be  nursed  by 
her  mother  and  husband.  The  mother  soon  after  began  to  show  evidence 
of  consumption,  and  followed  the  daughter  in  about  six  months.  It  is  now 
two  years  since  the  death  of  the  latter,  and  the  husband  is  failing  percep- 
tibly, showing  evidences  of  softening,  and  the  other  accompaniments  of  the 
third  stage." 

Dr.  Anson  Hurd,  of  Finley,  0.,  says  :  "I  am  a  recent  convert  to  the  doc- 
trine of  contagion,  but  I  cannot,  in  the  limited  space  allowed  me,  give  more 
than  the  following  instance  :  viz.,  the  M.  family.  Father,  mother,  and  son. 
The  son  died  one  year  before  the  mother  ;  the  tendency  being  inherited  from 
her.  The  father,  a  robust  man  from  robust  stock,  in  whose  parentage  back 
for  two  or  three  generations  there  had  never  been  any  case  of  consumption, 
tubercular  or  scrofulous  affection,  died  one  year  after  his  wife,  and  two 
years  after  the  son.  He  nursed  the  latter  (an  only  son),  also  the  wife, 
attentively,  sleeping  frequently  in  the  same  bed.  He  began  to  cough,  show 
signs  of  elevation  of  temperature  before  the  wife  died.  He  said,  '  Doctor, 
you  need  not  deny  it;  consumption  is  catching,  and  I  have  caught  it  from 
my  wife  or  son,  and  shall  die  of  it.'  And  he  did  ;  the  disease  developed 
rapidly  with  all  the  signs  and  characteristics  of  true  consumption." 

Any  further  quotations  would  only  prove  wearisome  repetitions  of  similar 
facts. 

The  already  large  number  has  been  thus  drawn  out  to  show  impressively 
the  grounds  upon  which  convictions  appear  to  have  been  based. 

We  cannot  shut  our  eyes  to  the  fact  that  startling  cases  do  present  them- 
selves, which  seem  to  confirm  the  theory  of  contagion  or  infection. 

Starting  originally  in  practice  with  the  belief  that  consumption  is  com- 
municable only  from  parent  to  offspring,  I  have  for  several  years  been  con- 
vinced that  there  is  great  danger  in  too  close  contact  with  those  in  the 
latter  stages,  and  for  a  more  positive  view  have  instituted  the  present 
inquiry. 


154 


Hold  en,  Is  Consumption  Contagious? 


[July 


I  can  enumerate  at  least  a  score  of  cases  which  have  been  watched  with 
this  very  object  in  view,  and  in  which  the  result  lias  been  the  same. 
Wives  after  husbands,  husbands  after  wives,  intimate  companions  and  faith- 
ful nurses,  who  slept  in  the  same  bed,  or  wore  the  same  clothing,  have 
fallen  victims.  Of  course  it  is  not  to  be  intimated  tliat  all,  or  even  a 
majority,  can  be  affected  by  contagion  any  more  than  in  those  diseases 
now  indisputably  contagious.  Malignant  scarlet  fever,  diphtheria,  and 
cerebro-spinal  meningitis  are  braved  by  faithful  nurses  and  friends  who 
escape  in  more  than  a  majority  of  instances. 

To  prove  contagion  is  no  easier  now  than  when  erysipelas  had  its  de- 
fenders, and  the  records  of  the  surgical  wards  of  the  hospitals  of  Paris  and 
Berlin  and  London  had  accumulated  a  fearful  mortality  ere  the  obdurate 
prejudices  of  the  profession  were  awakened  to  a  new  belief. 

The  records  of  the  great  hospital  for  consumptives  at  Brompton  may 
with  propriety  be  here  alluded  to,  and  none  the  less  so  because  they  enable 
us  most  conclusively  to  eliminate  from  our  inquiry  one  point  of  interest, 
viz.,  the  possibility  of  infection  through  the  atmosphere,  where  ventilation 
is  observed. 

These  statistics  were  prepared  by  Drs.  Cotton  and  Virtue  Edwards, 
and  show  that  of  the  numerous  nurses  and  attendants  en£a<red  during 
twenty-one  years,  only  one  nurse  and  one  servant,  and  no  chaplains, 
matrons,  secretaries,  or  even  porters  who  carried  out  the  dead,  had  died 
from  consumption.  Two  dispensers,  however,  fell  victims,  but  in  one  it 
was  not  clearly  traceable  to  his  stay  at  the  hospital,  and  indeed  appeared 
to  develop  only  after  his  change  to  some  other  occupation.  Now  we 
accept  these  facts  as  conclusive  against  infection  where  ventilation  is  per- 
fect, and  if  we  may,  as  I  believe  we  should,  draw  a  sharp  line  between 
infection  and  contagion,  we  may  dismiss  atmospheric  poison  at  once  from 
the  case,  and  look  to  the  influence  of  contact  as  the  source  of  danger. 

At  Brompton  the  patients  and  attendants  never  were  so  intimately 
associated  as  to  test  the  danger  of  contact,  as  by  sleeping  in  the  same 
bed,  the  wearing  of  the  same  clothing,  etc.  ;  and  as  regards  our  practical 
view  of  the  question,  and  its  bearing  upon  husbands  and  wives  and  brothers 
and  sisters,  the  statistics  give  no  light. 

We  shall  therefore  not  again  in  this  essay  use  the  words  contagion  and 
infection  as  synonymous. 

Now  to  return  to  our  original  proposition.  Do  practical  experience 
and  observation  seem  to  show  that  consumption  is  contagious?  We  must 
answer,  they  certainly  appears  to  do  so. 

For  the  second  part  of  the  original  query,  admitting  errors  of  clinical 
deduction,  can  the  products  of  retrograde  metamorphosis  of  tissue,  as 
thrown  off  by  the  lungs  and  skin,  produce  in  a  healthy  person  the  same  or 
other  or  any  disease  ?   We  may  simply  paraphrase  by  asking,  If  it  appears 


1878.] 


Hold  en,  Is  Consumption  Contagious? 


155 


to  be  shown  by  practical  experience,  is  such  contagion  compatible  with 
the  pathological  possibilities  ? 

We  are  at  once  brought  into  contact  with  the  inquiry  as  to  the  essential 
element  of  consumption  and  its  origin.  If  it  may  be  due  to  the  character 
of  the  soil  and  deficient  drainage,  as  maintained  by  some,  and  it  is  indu- 
bitable that  the  disease  favours  a  locality  whose  subsoil  is  clayey,  then  the 
mere  tact  of  two  persons  being  exposed  to  a  similar  influence  is  brought 
forward  against  a  possible  contagion  emanating  from  the  first  one  sick  ; 
but  may  not  this  be  urged  against  any  and  every  disease  now  admitted  to 
be  contagious — typhoid,  yellow  fever,  diphtheria,  scarlatina,  etc.  ?  It 
appears  invalid  as  against  more  direct  testimony. 

Dampness,  variable  temperature,  and  indeed  any  and  all  conditions 
common  to  the  sick  and  well,  must  be  dismissed  in  like  manner  ;  since  if 
these  be  assigned  for  any  given  case  where  a  well  and  strong  person  has 
been  exposed  to  the  influence  of  the  sick,  a  valid  answer  would  be  that 
others  equally  well  did  not  succumb,  or  that,  as  in  many  of  the  instances 
given,  the  same  person  had  been  a  constant  resident  of  the  locality  without 
detriment.  Of  the  various  theories  maintained  by  writers  with  more  or 
less  tenacity,  none  is  more  difficult  to  withstand  as  an  argument  against 
contagion  than  that  of  MacCormac,  viz.,  the  "breathing  of  rebreathed 
air."  Since  if  the  simple  breathing  of  exhaled  air  from  healthy  lungs 
loaded  with  the  products  of  a  normal  excretion  would  suffice  to  produce 
consumption,  the  confinement  of  the  frequently  closed  rooms  sought  by 
those  ill  with  the  disease,  together  with  the  anxiety  and  watching  of  the 
one  acting  as  the  attendant,  would  be  at  once  a  sufficient  reason  for  its 
outbreak  in  him  or  her,  aside  from  the  exposure  to  the  person  already  ill. 
In  answer  to  this  we  would  say  that  if  healthy  lungs  yield  a  sufficiently 
vitiated  atmosphere  to  develop  disease — and  we  admit  that  one  of  the  chief 
elements  of  the  disease,  viz.,  impaired  nutrition,  is  favored  thereby — how 
much  more  would  this  be  the  case  when  the  air  is  contaminated  by  the 
exhalations  from  necrobiotic  tissue. 

Now  we  have  not  simply  to  deal  with  an  impairment  of  nutrition,  such 
as  might  arise  from  neurotic  or  hasmic  changes,  but  a  specific  disease,  the 
actual  morbific  element  being  yet  unknown  to  us  in  spite  of  the  years  of 
arduous  scientific  labour  spent  upon  it. 

Cases,  moreover,  do  occur  of  apparent  contagion  among  husbands  and 
wives  when  every  attention  is  given  to  ventilation  and  pure  air,  it  being 
evident  however  that  absolute  purification  would  diminish  the  probability 
of  contagion  as  it  clearly  does  in  cases  of  variola. 

We  need  not,  however,  dwell  upon  the  various  theories  advanced  as  to 
the  origin  of  consumption;  since,  even  if  we  assume  it  to  be  local  and  in- 
flammatory, there  must  yet  be  behind  that,  something  which  determines 
its  subsequent  difference  from  a  simple  inflammation,  and  an  inherent  some- 


156 


Hold  en,  Is  Consumption  Contagious? 


[July 


thing  even,  which  decides  whether  the  products  of  inflammatory  action 
shall  be  absorbed  or  undergo  caseous  degeneration. 

To  my  own  mind,  after  careful  study  of  the  subject,  as  well  as  of  the 
views  of  eminent  authors,  nothing  is  more  clear  than  that  the  disease  is,  in 
its  very  earliest  incipiency,  clear  back  of  any  untoward  development,  an 
integer  of  the  bioplasm  of  the  blood,  just  as  certainly  as  the  Roman  nose 
of  the  Polish  Jew  is  an  essential  element  of  the  ovum  or  spermatozoon  of 
his  progenitor.  This  is  the  opinion  of  Dr.  C.  B.  J.  Williams,  whose  able 
exposition  of  the  view  may  be  found  in  his  work  on  Consumption.  It  is, 
it  seems  to  me,  the  only  rational  hypothesis,  and  reaches  the  "  reiz"  of 
Virchow,  and  the  primitive  departure  from  a  norma!  condition  alluded  to 
by  Southey  in  his  "  Nature  and  Affinity  of  Tubercle"  as  the  "  rift  within 
the  lute  which  by  and  by  will  make  the  music  mute." 

Even  with  this  hypothesis  we  are  yet  unable  to  say  in  what  this  change 
of  the  bioplasm  consists;  still,  if  it  is  admitted,  then  we  ask  what  external 
influences  may  so  change  the  character  of  the  blood  ?  Those  which  result 
in  rheumatism  and  gout  have  been  studied  with  such  success  that  reme- 
dies have  been  brought  to  bear  upon  scientific  principle-:  and.  although 
we  do  not  feel  that  the  development  of  uric  and  lactic  acid,  as  causes,  has 
been  satisfactorily  proven,  the  external  influences  that  produce  the  change 
are  well  known,  and  the  theory  is  in  a  therapeutic  sense  sustained. 

As  in  rheumatism,  we  know  what  external  influences  will  develop  con- 
sumption, and  that  these  influences  work  witli  greater  certainty  upon  a 
person  predisposed  thereto.  Via  may  go  further,  and  say  that  as  many 
supposed  healthy  persons  carry  for  an  indefinite  time  the  pulmonary  states 
which  afford  favourable  soil  for  the  disease,  they  are  predisposed  in  other 
senses  than  by  mere  heredity.  Among  these  influences  are  anxiety,  loss 
of  rest,  wearisome  watching,  and  impure  air  ;  and  we  purposely  come  back 
to  the  strongest  argument  against  the  individual  instances  of  supposed  con- 
tagion that  has  yet  been  urged,  viz.,  that  not  contagion,  but  this  very 
watching  and  anxiety,  etc.,  adequately  explain  the  facts.  Unfortunately 
for  this  explanation,  experience  shows  that  all  these  are  exaggerated ;  the 
apparent  contagion  occurs  where  the  exposed  parties  are  far  from  being 
troubled  by  anxiety  or  watching,  and  where  ventilation  is  most  carefully 
observed.  Of  this  fact  I  am  convinced  by  clinical  experience,  several  of 
my  own  cases  being  only  confined  to  the  room  or  bed  for  a  few  days,  and 
requiring  no  especial  attention  ;  and  in  one  case  particularly,  the  wife  was 
rather  impatient  that  her  husband  delayed  so  long  his  going  off. 

This,  however,  is  a  digression ;  change  in  the  blood,  whether  from  mal- 
nutrition or  mal-assimilation,  and  the  operation  of  external  influences 
being  admitted,  may  one  of  these  external  influences  be  the  exhalation 
from  lungs  by  respiration,  or  from  the  body  by  perspiration  of  a  consump- 
tive? To  carefully  purify  the  water  in  a  spirometer,  and  allow  a  large 
number  of  consumptives  to  breathe  through  it,  seemed  to  be  a  sure  method 


1878.] 


Hold  en,  Is  Consumption  Contagious? 


157 


of  obtaining  the  disease-germs,  if  such  existed.  The  water,  after  a  reason- 
able time,  swarmed  with  bacteria  and  germs  of  organic  life  ;  but,  unfortu- 
nately, a  similar  condition  resulted  when  only  healthy  persons  had  respired 
in  the  same  manner,  and  it  became  at  once  evident  that  the  germs  might 
belong  to  the  air,  and  were  not  of  necessity  obtained  from  the  respiratory 
tract. 

Putrefactive  changes,  however,  occurred  far  more  rapidly  in  one  than 
the  other,  and  odours  of  a  sickening  character  emanated  sometimes  almost 
immediately  from  the  water  used  by  the  consumptives. 

This  method  of  investigation,  therefore,  offered  no  more  satisfactory  re- 
sult, and  was  discontinued.  The  evidence  of  some  influence  favouring 
putrefactive  changes  having  passed  into  the  water,  however,  suggests  that 
possibly  careful  search  might  show  the  microsporon  septicum  believed  by 
Klebs  to  be  the  fungus  which  gives  to  pus  an  infectious  character  (Wag- 
ner. Man.  Gen.  Path.,  p.  106),  or  some  other  microzyme  as  yet  unnamed. 
The  failure  thus  far  to  find  a  definite  fungus  is  by  no  means  any  evidence 
that  infection  may  not  exist  in  this  very  quality  which  favoured  the  early 
putrescence  of  the  water,  since  the  germ  theory  of  contagion  is  far  from 
being  proven,  and  the  chemical  theory  is  full  as  ably  supported. 

Orth,  although  favouring  the  former,  yet  shows  that  destruction  of  the 
bacteria  of  infectious  liquids  does  not  wholly  destroy  their  infectious  cha- 
racter {Arch,  of  Exp.  Path.,  1873,  p.  81).  Not  to  further  pursue  the 
question  of  transmission  by  atmospheric  agency,  which,  as  has  already 
been  stated  above,  is  weak  and  almost  positively  negatived  by  the  expe- 
rience of  the  Brompton  Hospital,  we  may  with  more  interest  and  profit 
study  the  influence  of  direct  contact. 

In  reviewing  all  the  cases  collected,  it  cannot  fail  to  be  noticed  that  the 
best  authenticated  ones  are  those  of  husbands  and  wives  who  have  slept  in 
the  same  bed,  of  brothers  or  friends  who  have  worn  the  same  clothing,  or 
of  women  who  have  borne  children  to  consumptive  fathers. 

The  most  positive  among  the  non-contagionists  almost  invariably  qualify 
their  assertions  by  the  advice  to  their  brother-physicians  not  to  allow  the 
consumptives  to  sleep  with  healthy  persons. 

And  Dr.  C.  B.  J.  Williams,  one  of  the  most  lucid  writers  on  consump- 
tion of  modern  times,  after  emphatic  denial  of  the  possibility  of  communi- 
cation of  the  disease  from  one  person  to  another,  ends  with  the  following 
contradiction  :  "I  yet  think  that  both  reason  and  experience  indicate  that 
a  noxious  influence  may  pass  from  a  patient  in  advanced  cases,  .... 
and  may  produce  the  same  disease."  Not  may  produce  disease,  but  the 
same  disease. 

The  influences  that  emanate  from  the  body  of  a  consumptive  are  such 
as  must  of  necessity  accompany  increased  elimination  of  the  products  of 
retrograde  metamorphosis.  The  lungs  crippled  in  their  power  to  do  their 
share,  and  the  rapid  chemical  changes  going  on  in  the  tissues  to  render  an 


158 


IIolden,  Is  Consumption  Contagious? 


increased  elimination  necessary,  the  skin  is  called  upon  to  do  a  double  duty  ; 
not  only  is  it  relaxed  and  devoid  of  its  power  to  equalize  the  temperature 
of  the  body  by  its  steady  elimination  of  insensible  perspiration,  but  it 
pours  out  its  discharges  upon  slight  exercise  or  nervous  excitement,  and  in 
the  latter  stages  drenches  the  failing  patient  with  the  colliquative  sweats 
so  unmistakable  and  alarming. 

That  this  sweating  is  always  the  reaction  of  pyrexia  can  hardly  be  for 
a  moment  maintained,  as  it  occurs  frequently  without  previous  elevation 
of  temperature  ;  yet,  when  it  is  the  sequela  of  fever,  it  must  be  the  more 
heavily  laden  with  the  debris  of  a  malnutrition  which  cannot  fast  enough 
be  rid  of  its  own  ashes  (if  we  may  thus  intrude  so  suggestive  a  metaphor). 
That  this  sweat  must  be  so  laden,  we  cannot  doubt ;  it  is  drawn  directly 
from  the  circulation,  it  is  prone  to  rapid  decomposition,  and  is  to  the  senses 
as  suggestive  of  decay  as  it  is  possible  to  be. 

Evaporation  of  its  watery  constituents  deposits  its  excrementitious  solids 
on  the  sheets  or  the  clothing  most  immediately  in  contact  with  the  body. 
That  these  are  in  small  quantities  is  of  course  conceded  ;  the  solids  of  nor- 
mal perspiration  are  less  than  half  of  one  per  cent,  of  the  fluid  itself. 
According  to  Favre,  as  quoted  in  Flint's  recent  Physiology  of  Man,  care- 
ful analysis  gives  the  following  in  100,000  parts  : — 

Water   995.573 


Urea   0.043 

Fatty  matters   0.014 

Alkaline  lactates  ........  0.317 

"      sudorates        .       .       .       .       .       .       .  1.562 

Chloride  of  sodium   2.230 

"        potassium    .......  0.244 

Alkaline  sulphates   0.012 

phosphates   a  trace. 

"       albuminates     .......  0.005 

"       earthy  phosphates   ......  a  trace. 

Epidermic  debris   a  trace. 


Now,  in  comparison  with  this,  an  analysis  of  the  sweat  from  patients  in 
the  last  stages  of  consumption  would  be  instructive,  but  the  difficulties  in 
the  way  of  an  analysis  involving  such  infinitesimals  have  prevented  its 
completion.  I  have  been  able  only  to  determine  the  fact  that  the  albumi- 
nates, sudorates,  and  urea  exist  in  greater  quantity,  as  might  have  been 
inferred,  and  that  the  perspiration  is  more  truly  excrementitious  in  cha- 
racter than  normal. 

The  quantity  of  this  eliminated  material  is  small;  yet  the  long  continu- 
ance of  the  process  would,  in  my  opinion,  supply  a  sufficient  accumulation 
of  it  to  endanger  a  healthy  person. 

The  question  as  to  the  absorbent  powers  of  the  skin  is  settled  by  phy- 
siologists, and  indeed  is  easily  proven.  The  fact  that  the  health  of  a 
well  person  will  deteriorate  under  the  nightly  contact  of  an  invalid,  what- 


1878.]  Lewis,  Treatment  of  Malarial  Fevers.  159 


ever  be  his  disease,  and  that  a  healthful  child  will  grow  ill  from  like  asso- 
ciation with  an  elderly  person  whose  vital  powers  are  failing,  ivitliovt  active 
disease,  are  matters  of  daily  experience  ;  and  the  conclusion  that  personal 
contact,  if  intimate  and  continued,  with  one  who  has  both  active  disease 
and  failing  vitality,  will  not  only  deteriorate  health,  but  actually  produce 
similar  disease,  is  more  than  plausible,  indeed  is  proven  by  the  following 
conclusions  of  our  argument : — 

1st.  The  general  experience  we  have  drawn  upon  favours  such  belief. 

2d.  Most  authorities,  even  among  the  non-believers  in  infection,  con- 
cede such  danger  from  intimate  contact ;  and — 

3d.  Such  a  theory  harmonizes  as  no  other  can  the  Opinions  of  careful 
observers. 

To  epitomize  concisely,  therefore,  we  believe  that  consumption  is  com- 
municable in  its  later  stages  by  means  of  soluble  excrementitious  matter 
thrown  off  by  the  skin  and  deposited  on  the  bedding  and  underclothing,  or 
in  any  other  manner  brought  into  contact  with  the  naked  surface  of  a 
healthy  body  ;  and  that,  although  in  some  instances  this  may  be  thrown 
otf  without  development  into  new  disease,  it  is  yet  very  liable  to  be  so 
developed,  and  more  liable  where  the  healthy  person  is  by  heredity  or 
depression  in  a  favourable  state  for  its  reception  ;  and,  finally,  that  the 
idea  of  infection  or  communication  by  the  atmosphere  is  not  sustained,  and 
is  rare  even  if  it  is  possible. 
13  Central  Avenue,  Newark. 


Article  XVI. 

Ox  the  Importance  of  Combining  Morphia  with  Quinia  in  the  Treat- 
ment of  Malarial  Fevers.  By  Meriwether  Lew^is,  M.A.,  M.D.,  of 
Lenoir,  Tennessee. 

With  many  physicians  it  is  an  established  principle  of  therapeutics,  that 
whenever  there  is  physical  pain  it  is  always  a  good  and  safe  indication  to 
relieve  it.  Acting  upon  this  principle  from  the  very  beginning  of  my 
practice,  I  soon  became  fully  convinced  of  its  importance,  and,  conse- 
quently, morphia  has  ever  since  stood  high  upon  my  list  of  favorite  thera- 
peutic agents. 

As  my  patients  frequently  complained  of  severe  pain  during  attacks  of 
intermittent  fever,  I  soon  began  to  combine  morphia  with  my  prescriptions 
of  quinia  ;  without  expecting,  however,  any  further  benefit  from  the  opiate 
than  the  temporary  relief  of  pain.  Carefully  observing  the  effects  of 
treatment,  I  began  to  notice  that  the  patients  who  received  morphia  in 
addition  to  the  general  treatment  recovered  more  rapidly  than  those  who 
did  not  take  the  opiate.     In  1872  I  had  just  located  at  Lenoir,  where 


160 


Lewis,  Treatment  of  Malarial  Fevers. 


[July 


malarial  fever  was  then  prevailing  to  an  extent  hitherto  unknown.  With 
such  clinical  advantages  before  me,  it  required  but  a  short  time  to  estab- 
lish the  conviction  in  my  own  mind  that  a  ten-grain  dose  of  quinia  com- 
bined with  a  third-  or  half-grain  dose  of  morphia  would  break  up  an  attack 
of  intermittent  fever  with  far  greater  certainty  than  would  a  twenty-grain 
dose  of  quinia  alone. 

Another  consideration  also  induced  me  frequently  to  combine  morphia 
with  quinia.  Hydrobromic  acid  had  not  then  been  introduced  ;  and  as 
anything  less  than  fifteen  grains  of  quinia  proved,  when  given  alone, 
utterly  inefficient  in  the  treatment  of  severe  cases  of  malarial  fever,  my 
patients  were  often  affected  with  distressing  tinnitus  aurium.  But  com- 
bining the  morphia  and  quinia,  I  found  that  severe  cases  of  malarial  fever 
could  be  relieved  by  one-half  of  the  former  dose  of  quinia  ;  and  that,  owing 
to  the  comparatively  small  dose  required,  there  was  perfect  immunity 
from  all  the  annoying  cerebral  symptoms  resulting  from  the  administration 
of  large  doses  of  the  sulphate  of  quinia. 

For  six  years  I  have  carefully  studied  the  comparative  value  of  quinia, 
with  and  without  morphia,  in  the  treatment  of  intermittent  and  remittent 
fevers.  Indeed,  I  have  kept  an  unbroken  record  of  the  diagnosis  and 
treatment  of  every  case  for  which  I  ever  prescribed  or  operated,  varying, 
of  course,  in  extent  and  fullness  with  the  interest  and  importance  of  the 
case,  but  always  sufficient  to  show  the  nature,  treatment,  and  result,  no 
matter  how  trivial  the  case  should  appear. 

Looking  over  these  records,  since  Aug.  1872,  I  find  that  I  have  treated, 
prior  to  Jan.  1878,  461  cases  of  malarial  fever.  Of  these  cases,  317  re- 
ceived (exclusive  of  the  general  treatment  which  was  the  same  in  all  the 
cases  requiring  it)  quinia  and  morphia  combined,  either  in  powder  or  in 
aromatic  sulphuric  acid  :  while  144  cases  were  treated,  as  nearly  as  possi- 
ble, in  the  same  way,  but  without  any  opiate  whatever.  The  average 
number  of  chills  occurring  subsequent  to  date  of  attendance  in  the  cases 
treated  on  the  combined  plan  was  l^W;  while  the  average  number  in  the 
cases  treated  without  morphia  was  S^3^.  These  results  show  the  great 
advantages  of  the  combined  treatment  over  the  administration  of  quinia 
alone. 

In  regard  to  the  modus  operandi  of  the  opiate  in  such  cases,  I  deem  it 
unnecessary  to  offer  any  remarks,  but  will  simply  formulate  the  conclu- 
sions to  which  I  have  been  led  by  the  study  of  the  records  of  my  cases. 

1st.  The  combination  of  an  opiate  with  quinia  insures  an  earlier  and 
more  complete  cure  of  intermittent  and  remittent  fevers,  than  quinia  alone ; 
2d.  Less  quinia  is  required,  and  hence  there  is  less  cerebral  disturbance  ; 
and,  3d.  Any  paroxysm  of  intermittent  or  remittent  fever  may  be  aborted 
by  the  use,  at  the  proper  time,  of  a  decided  dose  of  morphia,  and  quinia 
with  reasonable  certainty. 


1878.] 


161 


REVIEWS. 

Art.  XVII. — Claude  Bernard  and  his  Physiological  Works. 

Claude  Bernard  was  born  on  the  twelfth  of  July,  1813,  and  died  on 
the  tenth  of  February,  1878,  in  the  sixty-fifth  year  of  his  age.  About  the 
year  1834,  a  young  man  hardly  twenty-one  years  of  age,  he  entered  Paris, 
bringing  with  him  a  tragedy.  In  his  native  village,  Saint- Julien,  near 
Villefranche  ( Rhone) ,  he  had  studied  pharmacy.  Aspiring  to  fame  in  the 
world  of  letters,  he  had  written  a  vaudeville  which  had  been  played  at 
Lyons.  Dissuaded  by  Saint-Marc  Girardin  from  the  course  which  he 
had  marked  out  for  himself,  he  entered  upon  the  study  of  medicine  soon 
after  his  arrival  at  Paris.  In  1839  he  was  admitted  an  interne,  having 
been  successful  in  the  concours,  into  one  of  the  hospitals  of  Paris.  The 
practical  work  of  his  profession,  however,  failed  to  satisfy  the  full  measure 
of  his  aspirations,  and  he  did  not  find  in  it  the  vocation  to  which  he  was  des- 
tined. Although  he  published,  in  conjunction  with  Huette,  a  superb  work 
upon  Operative  Medicine,  which  was  translated  into  English,  German, 
Dutch,  Italian,  and  Spanish,  his  success  as  a  writer  upon  surgery  has  been 
so  far  overshadowed  by  his  brilliant  achievements  in  physiology,  that  this 
work,  upon  which  another  might  have  built  an  enduring  reputation,  is  now 
regarded  merely  as  an  episode  in  his  remarkable  career.  If  Avhat  is  called 
genius  ever  belongs  to  men  of  science,  Claude  Bernard  was  a  man  of 
genius.  In  the  chair  of  medicine  in  the  College  of  France,  he  was  the 
immediate  successor  of  Magendie,  and  he  occupied  a  professorship  that 
had  been  filled  by  Vidius,  Sylvius,  Riolan,  Corvisart,  and  Laennec. 
His  successor  may  bear  comparison  with  any  of  his  predecessors  more 
easily  than  with  Claude  Bernard. 

A  complete  account  of  the  labours  of  Bernard  since  he  first  entered  the 
field  of  what  may  be  termed  experimental  physiology  would  be  the  great- 
est part  of  a  history  of  the  progress  of  physiology  for  the  past  thirty -five 
years.  The  influence  of  his  method  is  now  felt  wherever  physiology  is 
studied.  Investigators  in  all  parts  of  the  civilized  world  are  now  treading 
in  the  paths  opened  by  Bernard.  His  younger  disciples  may  live  to  see 
the  day  when  all  but  Frenchmen  will  forget  that  Bernard  was  born  in 
France,  and  will  remember  only  that  his  name  and  fame  belong  to 
Physiology. 

The  first  important  physiological  memoir  published  by  Bernard  was 
entitled  Recherches  anatomiques  et physiologiques  sur  la  corde  da  tympan, 
1843.  Bellingeri,  in  1818,  discussed  the  question  as  to  whether  the  sense 
of  taste  in  the  tongue  was  derived  from  the  -  proper  filaments  of  the  fifth 
nerve,  or  from  the  facial  by  the  chorda  tympani.  In  1821  Roux  described 
loss  of  taste  on  one  side  of  the  tongue  attending  paralysis  of  the  facial. 
In  1831  Montault  described  the  same  condition  in  certain  cases  of  facial 
palsy.  Notwithstanding  these  observations,  however,  the  general  opinion 
was  that  the  lingual  branch  of  the  fifth  was  a  nerve  of  taste,  and  this  was 
described  in  works  upon  anatomy  and  physiology  as  the  gustatory  branch 
No.  CLI  July  1878.  11 


162 


Re  vie  w  9 . 


[July 


of  the  fifth.  Bernard  gave  a  minute  description  of  the  course  and  rela- 
tions of  the  chorda  tympani  in  different  classes  of  animals  and  in  man. 
He  showed,  by  direct  experiments  upon  animals,  that  destruction  of  this 
nerve  had  no  effect  upon  the  general  sensibility  of  the  tongue,  but  that  it 
affected  the  sense  of  taste  alone.  In  a  second  memoir,  published  in  1845,  he 
confirmed  the  results  of  his  experiments  upon  the  inferior  animals  by  obser- 
vations upon  the  human  subject.  Bernard  established  the  definite  scien- 
tific fact  that  the  chorda  tympani  presides  over  the  sense  of  taste  in  the 
anterior  portion  of  the  tongue.  As  such  it  remains  and  is  accepted  at  the 
present  day  by  nearly  all  physiologists. 

In  1844  Bernard  published  an  article  on  the  gastric  juice,  in  which  he 
recited  a  number  of  ingenious  experiments  with  regard  to  the  elimination 
by  the  gastric  mucous  membrane  of  certain  foreign  substances  introduced 
into  the  circulation.  He  caused  an  animal  to  swallow  a  salt  of  iron,  and 
then  injected  a  solution  of  ferrocyanide  of  potassium  into  the  veins.  He 
noted,  after  a  short  interval,  the  formation  of  Prussian  blue  in  the  stomach, 
showing  that  the  ferrocyanide  had  passed  into  the  gastric  juice.  He  made 
at  the  same  time  other  experiments,  injecting  cane-sugar,  gelatine,  and 
albumen  into  the  bloodvessels ;  but  these  experiments  were  not  so  impor- 
tant as  those  which  he  made  later,  in  conjunction  with  Barreswil,  upon 
the  nature  of  the  free  acid  of  the  gastric  juice,  showing,  in  the  first  place, 
that  a  certain  degree  of  acidity  of  the  gastric  juice  was  necessary  to  its 
digestive  power,  the  nature  of  the  acid  being  not  absolutely  essential.  In 
1844  he  published  another  memoir,  showing  the  arrest  of  stomach  diges- 
tion by  section  of  the  pneumogastric  nerves.  It  will  be  remembered  that 
our  accurate  knowledge  of  stomach-digestion  dates  from  the  experiments 
upon  Alexis  St.  Martin,  published  by  an  American  physician,  Dr.  Beau- 
mont, in  1833,  and  that  the  observations  by  Bernard  were  made  imme- 
diately after  the  experiments  published  by  Blondlot  in  1843,  when  very 
little  was  known  of  the  physiological  action  of  the  stomach.  Aside  from 
one  of  the  most  important  discoveries  made  by  Bernard,  viz.,  the  action 
of  the  pancreatic  juice  in  digestion,  he  made,  very  early  in  his  career,  im- 
portant observations  upon  the  mixed  digestive  fluids  found  in  the  small 
intestine,  and  he  showed  their  action  upon  various  alimentary  substances, 
including  the  albuminoids. 

In  1848  Bernard  made  a  discovery  which  attracted  more  attention  than 
any  new  development  in  physiological  science  since  the  discovery  of  the 
distinct  properties  of  the  anterior  and  posterior  roots  of  the  spinal  nerves. 
In  that  year  he  published,  in  the  Archives  generales  de  medecine,  a  memoir 
entitled  De  Vorigine  du  sucre  dans  Veconomie  animate.  This  publica- 
tion, which  afterward  appeared  in  extenso  in  the  Oomptes  Hendus  de 
V  Academie  des  Sciences  in  1850,  and  which  received  the  prize  of  experi- 
mental physiology  in  1857,  made  a  most  extended  and  profound  impres- 
sion. The  observations  therein  detailed  were  soon  repeated  in  France, 
Germany,  England,  and  America,  and  Bernard  became  recognized  at 
once  as  one  of  the  greatest  of  living  physiologists. 

It  is  difficult  to  imagine  a  discovery  so  extended  in  its  applications,  and 
so  complex  as  this  has  proved  to  be  in  its  relations,  which  could  have  been 
more  thoroughly  elaboiated  by  its  author.  In  the  first  place,  the  method  of 
its  development  is  a  perfect  illustration  of  the  system  of  investigation  which 
dates  in  physiology  from  the  discovery  of  the  circulation  of  the  blood  by 
Harvey,  and  which  is  so  strongly  set  forth  as  the  only  reliable  system  of 
scientific  research  by  Bacon.    Followed,  as  it  was,  by  numerous  other 


1878.]  Claude  Bernard  and  his  Physiological  Works.  163 


important  discoveries  by  Bernard,  it  is  not  to  be  wondered  at  that  enthu- 
siastic workers  sprang  into  existence  wherever  physiology  was  studied,  fol- 
lowers of  what  began  to  be  known  as  the  French  school.  It  will  not  be 
difficult  for  many  who  read  this  notice  to  remember  the  deep  impres- 
sion made  upon  medical  men  not  specially  interested  in  pure  physiology 
by  the  researches  of  Bernard.  He  was  visited  by  nearly  all  physicians 
who  went  from  this  country  to  Europe  to  study  disease  in  the  hospitals. 
We  now  have  in  our  mind  the  remembrance  of  accounts  given  us  by  old 
practitioners  of  medicine,  of  the  wonderful  dexterity  in  experimentation, 
the  unvarying  affability,  and  the  patient  and  kind  attention  always  given 
to  strangers  by  the  great  French  physiologist.  In  ingenuity  in  devising 
new  methods  of  verifying  and  enforcing  his  doctrines,  and  in  skill  in  their 
execution,  no  one  has  ever  equalled  Claude  Bernard.  A  practical  physio- 
logist, whose  studies  began  at  the  time  when  he  was  at  the  zenith  of  his 
renown,  could  hardly  write  a  notice  of  his  works  that  would  appear  to  be 
less  than  a  eulogy.  He  passed  away  as  he  lived ;  and  he  corrected  the 
proofs  of  an  unfinished  publication  upon  his  death  bed. 

The  story  of  the  discovery  of  the  glycogenic  function  of  the  liver  is  a  most 
interesting  illustration  of  the  method  of  study  which  Bernard  followed  out 
with  such  remarkable  success.  In  1848,  having  reflected  that  sugar  was 
sometimes  discharged  in  the  urine  in  disease,  he  conceived  the  idea  that 
there  must  be  some  organ  in  the  body  designed  to  consume  and  destroy  it 
as  sugar,  in  health.  His  first  experiments  were  undertaken  with  the  view 
of  discovering  this  organ  and  its  functions.  With  this  object  in  his  mind, 
he  fed  a  dog  with  a  mixture  containing  large  quantities  of  starch  and 
sugar,  and  attempted  to  follow  the  sugar  as  it  passed  in  the  blood  through 
the  various  organs.  He  analyzed  the  blood  of  the  portal  vein,  and  found 
sugar.  He  then  examined  the  substance  of  the  liver  and  the  blood  of  the 
hepatic  veins,  still  finding  sugar.  As  a  counter-experiment,  he  examined 
the  blood  and  the  substance  of  the  liver  in  a  dog  that  had  been  fed  exclu- 
sively upon  meat.  He  found  no  sugar  in  the  portal  vein,  but  it  existed 
in  abundance  in  the  liver  and  in  the  blood  of  the  hepatic  veins.  This  was 
the  discovery  of  animal  glycogenosis.  Unlike  most  great  discoveries,  no 
one  had  prepared  the  way,  and  the  discovery  was  made  unexpectedly  at 
the  very  threshold  of  the  experimental  investigation. 

The  perfection  of  detail  to  which  the  discovery  of  animal  glycogenosis 
was  brought  by  its  author  is  almost  without  a  parallel  in  the  history  of 
physiology.  Harvey  left  to  Malpighi  the  task  of  discovering  the  system  of 
vessels  connecting  the  arteries  with  the  veins  ;  but  Bernard  left  scarcely 
anything  for  his  contemporaries  or  his  successors  but  to  verify  his  results. 
In  his  memoir  published  in  1850,  he  showed  that  glycogenosis  exists  in  man, 
in  the  quadrumana,  the  carnivora,  rodentia,  ruminantia,  and  the  pachyder- 
mata,  as  well  as  in  birds,  fishes,  reptiles,  mollusks,  and  articulates.  He  has 
since  answered,  and,  indeed,  he  answered  to  a  great  extent  in  advance,  all 
the  objections  that  could  be  raised  against  his  conclusions.  In  successive 
publications,  he  showed  the  mechanism  of  the  production  of  sugar  by  the 
liver,  an  amyloid  substance,  which  he  called  glycogenic  matter,  being  formed 
first,  this  substance  being  gradually  converted  into  sugar,,  and  as  sugar  being 
taken  up  by  the  blood  of  the  hepatic  veins.  The  experiment  by  which  this 
was  demonstrated  was  the  following:  A  liver  taken  from  an  animal  just 
killed  was  washed  free  from  sugar  by  a  stream  of  water  passing  through  the 
bloodvessels.  From  such  a  liver  the  glycogenic  matter  may  be  extracted, 
or,  if  the  liver  be  kept  in  a  warm  place  for  a  number  of  hours,  sugar  will  make 


164 


Reviews. 


[July 


its  appearance  in  its  substance  by  the  change  of  a  portion  of  its  glycogenic 
matter.  In  the  course  of  his  investigations  upon  this  subject,  he  showed 
the  influence  of  digestion,  inanition,  and  various  other  conditions  upon 
glycogenesis.  He  divided  the  pneumogastric  nerves,  and  arrested  the  pro- 
duction of  sugar ;  he  stimulated  the  same  nerves,  and  exaggerated  its  pro- 
duction so  as  to  render  an  animal  diabetic.  He  irritated  the  floor  of  the 
fourth  ventricle,  and  produced  artificial  diabetes  (1849).  He  showed  the 
reflex  action  of  irritation  of  the  filaments  of  the  pneumogastrics  distributed 
to  the  lungs.  He  discovered  the  glycogenic  function  of  the  placenta,  which 
exists  before  this  function  is  performed  by  the  liver,  in  the  foetus.  Not  to 
follow  out  his  observations  in  their  order  and  in  full  detail,  his  experiments 
were  so  varied  and  numerous,  and  he  completed  the  discovery  so  thoroughly, 
that  the  name  of  Claude  Bernard  is  the  only  one  that  has  any  real  connec- 
tion with  the  function  of  glycogenesis  in  animals. 

The  next  important  discovery  made  by  Bernard  was  in  1848,  following 
closely  upon  the  publication  of  his  researches  upon  the  glycogenic  function 
of  the  liver.  At  that  time  our  knowledge  with  regard  to  the  function  of 
digestion  was  very  limited  and  indefinite.  Writers  described  a  process 
called  chymification,  as  occurring  in  the  stomach,  the  food  being  reduced  in 
this  organ  to  a  pultaceous  mass,  and  chylitication  in  the  small  intestine, 
where  the  food  became  liquefied  and  was  taken  up  in  the  form  of  chyle. 
Although  allusions  had  been  made  to  the  function  of  the  pancreas  in  the 
digestion  of  fats,  by  De  Graaf,  in  1671,  and  by  Eberle,  in  1838,  nothing 
definite  was  known  of  the  action  of  the  normal  pancreatic  juice  before  the 
announcement  of  the  discovery  of  its  true  function  by  Bernard  to  the  Soci- 
ety of  Biology  of  Paris,  in  1848,  the  experiments  dating  from  1840.1  In 
completeness  of  detail  and  in  perfection  of  logical  deduction  from  full  and 
definite  experimental  results,  the  history  of  the  function  of  the  pancreas 
as  given  by  Bernard  is  fully  equal  to  his  description  of  animal  glycogenesis. 
Before  the  publication  of  his  memoir,  the  pancreas  had  been  called  the 
abdominal  salivary  gland,  and  it  was  supposed  by  some  to  moderate  the 
acridity  of  the  bile,  an  idea  so  indefinite  that  it  hardly  merits  the  name 
of  an  hypothesis. 

Bernard  was  the  first  physiologist  who  obtained  pure,  normal  pancreatic 
juice  from  a  fistula  in  a  living  animal.  He  demonstrated  its  reaction,  its 
general  properties,  and  its  action  in  digestion,  not  only  upon  fats  but  upon 
other  alimentary  matters.  In  his  first  publication  he  answered  various 
objections  which  were  subsequently  made,  showing  that  the  fluid  discharged 
from  a  permanent  fistula,  or  from  a  fistula  of  several  days'  standing,  was 
abnormal.  He  showed  that  the  normal  pancreatic  juice  was  the  only  one 
of  the  digestive  fluids  that  would  instantly  form  a  complete  and  permanent 
emulsion  with  fats.  This  fact  he  demonstrated  in  various  classes  of  animals. 
He  also  showed  that  fatty  matters  passed  through  the  intestinal  canal  un- 
digested in  cases  of  serious  organic  disease  of  the  pancreas.  Fatty  diarrhoea 
coexistent  with  organic  disease  of  the  pancreas  had  been  observed  by  Dr. 
Richard  Bright  in  1832,  but  this  did  not  serve  to  direct  the  attention  of 
physiologists  to  the  action  of  the  pancreatic  juice  in  digestion.  Bernard 
noted  the  fact  that,  in  the  rabbit,  the  opening  of  the  pancreatic  duct  is 
several  inches  below  the  orifice  of  the  bile-duct.    He  showed  by  experi- 

1  We  have  mentioned  the  glycogenic  function  of  the  liver  first,  as  it  "vras  the  publica- 
tion of  this  discovery  which  seems  to  have  produced  the  more  decided  impression. 
The  discovery  of  the  action  of  the  pancreas  in  the  digestion  of  fats  was  published  at 
about  the  same  time. 


1878.] 


Claude  Bernard  and  his  Physiological  Works. 


165 


ment  that  lacteals  filled  with  white  chyle  first  appeared  in  this  animal 
below  the  opening  of  the  pancreatic  duct. 

In  1859  Bernard  published  a  second  series  of  experiments,  in  which  he 
showed  the  effects  of  destruction  of  the  pancreas  in  living  animals.  Ani- 
mals in  which  the  pancreas  had  been  destroyed  by  the  injection  of  melted 
tallow  into  the  ducts  died  of  inanition,  although  the  appetite  was  voracious 
and  large  quantities  of  food  were  taken,  showing  that  the  function  of  the 
pancreas  was  essential  to  life.  In  these  animals  fatty  matters  passed 
through  the  intestinal  canal  undigested,  and  the  digestion  of  meats,  also, 
was  incomplete.  In  addition  to  the  function  of  the  pancreatic  juice  in  the 
digestion  of  fats,  Bernard  demonstrated  its  action  upon  albuminoid  articles 
of  food  and  upon  cane-sugar,  showing  that  it  is  probably  the  most  impor- 
tant of  the  digestive  fluids,  and  the  one  possessing  the  most  varied  proper- 
ties and  functions.  His  description  of  the  functions  of  the  pancreas  left 
little  to  be  learned.  It  was,  like  most  of  his  systematic  series  of  investi- 
gations, complete  in  itself. 

Another  very  important  discovery  made  by  Bernard  early  in  his  career 
as  a  physiologist  was  that  of  the  functions  of  the  spinal  accessory  nerve 
in  connection  with  phonation.  This  was  published  first  in  1844,  thus 
antedating  the  publication  of  his  observations  upon  glycogenesis  and  upon 
the  functions  of  the  pancreas,  both  of  which  appeared  in  1848.  As  we 
progress  in  our  account  of  the  physiological  labors  of  Bernard,  we  find  it 
difficult  to  carry  out  an  analysis,  even  of  his  most  important  works  alone, 
in  a  strictly  chronological  order.  He  made  important  researches  in  con- 
nection with  nearly  every  subdivision  of  the  subject  of  physiology,  and, 
particularly  in  the  earlier  part  of  his  career,  his  experimental  labours  were 
enormous  and  exceedingly  varied.  Most  of  those  who  are  at  all  familiar 
with  physiological  literature  at  once  connect  the  name  of  Bernard  with 
the  discovery  of  the  sugar-producing  function  of  the  liver,  and  it  is  only 
natural  to  give  prominence,  early  in  this  notice,  to  his  experiments  upon 
this  subject ;  bet  a  more  connected  history  of  his  other  contributions  to 
physiological  knowledge  can  be  given,  if  we  classify  his  researches,  as  far 
as  possible,  according  to  the  systems  to  which  they  relate. 

Bernard's  contributions  to  our  knowledge  of  the  functions  of  the  diges- 
tive system  were  many  and  varied.  We  have  already  alluded  to  his  expe- 
riments upon  the  gastric  juice  and  stomach-digestion.  He  was  one  of  the 
first  to  recognize  the  importance  of  studying  the  combined  as  well  as  the 
successive  action  of  the  different  digestive  fluids,  introducing  a  truly  philo- 
sophic method  into  the  study  of  their  functions.  Among  the  earliest  of  his 
works  is  a  series  of  observations  upon  the  properties  and  functions  of  the 
saliva. 

In  1831  Leuchs  discovered  the  action  of  the  mixed  saliva  in  changing 
starch  into  sugar.  In  1845  a  commission,  consisting  of  Magendie,  Rayer, 
Payen,  and  others,  made  an  interesting  report  to  the  Academy  of  Sciences 
of  Paris  upon  the  mixed  saliva  of  the  horse ;  but  they  obtained  the  fluid 
by  causing  a  horse  to  eat  bran  that  had  been  carefully  washed,  taking  the 
mass,  as  it  was  swallowed,  from  an  opening  in  the  oesophagus,  and  sepa- 
rating the  saliva.  In  1847  Bernard,  taking  up  the  question  where  it  had 
been  left  by  the  commission,  carefully  studied  the  properties  of  the  pure 
secretions  taken  from  the  ducts  of  each  of  the  three  salivary  glands,  the 
properties  of  these  three  fluids  mixed,  and  the  properties  of  the  mixed 
saliva  and  the  mucus  of  the  mouth  and  pharynx.  Physiologists  now 
have  a  very  distinct  idea  of  the  time  of  secretion  and  the  properties  of  each 


166 


Reviews. 


[July 


of  the  three  varieties  of  saliva,  and  their  connection  with  mastication,  gus- 
tation, deglutition,  the  digestion  of  starch,  and  the  process  of  stomach- 
digestion.  It  is  not  too  much  to  say  that  these  definite  notions  depend 
mainly  upon  the  experiments  made  by  Bernard  since  1847. 

In  1850  Bernard  made  a  series  of  interesting  experiments  upon  the 
influence  of  the  pneumogastric  nerves  upon  the  cesophagus.  He  showed 
that  deglutition  was  impossible  immediately  after  section  of  these  nerves 
in  the  neck,  that  the  food  which  passed  below  the  pharynx  remained  in 
the  cesophagus  and  did  not  reacli  the  stomach,  and  that  the  so-called  vomit- 
ing, which  sometimes  occurs,  is  due  to  contraction  of  the  muscular  struc- 
ture of  the  oesophagus,  when  its  fibres  are  directly  excited  to  action  by 
distension  of  the  tube. 

In  the  summer  of  1855  the  lectures  delivered  by  Bernard  at  the  College 
of  France  were  devoted  to  the  subject  of  digestion.  They  were  published 
in  1856,  under  the  following  title:  Lemons  de  pltysiologie  experiment  ale 
appliquee  a  la  medecine;  tome  deuxihnc.  Cours  da  semestre  oVete  1855. 
These  lectures  contained  a  full  and  extended  account  of  all  of  his  discove- 
ries which  relate  to  digestion,  as  well  as  historical  resumes.  He  gave,  also, 
a  most  intelligent  and  appreciative  summary  of  the  observations  of  Dr. 
Beaumont  upon  Alexis  St.  Martin.  Later  researches  have  corrected  but 
few  errors  in  these  lectures  delivered  by  Bernard  in  1855.  His  first  pub- 
lished lectures,  delivered  in  the  winter  of  1854-55,  were  devoted  to  glyco- 
genosis. The  lectures  upon  digestion  were  the  first  which  embraced  a  large 
subject,  in  which  a  consideration  of  the  labours  of  others  was  necessarily  in- 
volved. In  fecundity  of  device  for  illustration,  and  in  directness  and  felicity 
of  diction,  there  was  nothing  at  that  time  superior  to  them  in  any  language. 
These  lectures,  which  were  read  extensively  in  this  country,  had  an  influ- 
ence beyond  the  mere  dissemination  of  the  discoveries  made  by  their  author. 
A  teacher  of  physiology,  reading  these  lectures,  could  see  at  once,  not  only 
a  definite  and  striking  account  in  words  of  the  actual  state  of  knowledge 
of  the  function  of  digestion,  but  he  could  picture  to  himself  the  vivid  man- 
ner in  which  the  subject-matter  must  have  been  enforced  upon  pupils  by 
the  brilliant  experiments  upon  living  animals  with  which  they  were 
illustrated. 

In  addition  to  the  discoveries  already  mentioned,  a  very  important 
and  suggestive  communication  was  made  by  Bernard  to  the  French 
Academy  of  Sciences,  in  March,  184G.  In  this,  Bernard  presented  the 
results  of  a  series  of  experiments  upon  herbivorous  and  carnivorous  ani- 
mals subjected  to  an  identical  diet,  and  a  comparison  of  the  urine  of  the 
same  animals  deprived  of  food.  He  found  that  fatty  matters  appeared  in 
the  chyle  of  rabbits  very  low  down  in  the  intestine,  and  he  states  that  this 
observation  led  him  to  the  discovery  of  the  organ  which  digested  fats. 
With  regard  to  the  effects  of  deprivation  of  food  upon  herbivora,  he 
showed  that  these  animals,  without  food,  became  true  carnivora,  inasmuch 
as  they  then  consumed  the  elements  of  the  blood.  Under  these  conditions 
the  urine  of  the  herbivora,  which  is  normally  alkaline,  turbid,  and  rich  in 
carbonates,  became  clear,  acid,  and  rich  in  phosphates  and  urea. 

In  1850  Bernard  presented  another  important  memoir  to  the  Academy 
of  Sciences.  By  a  series  of  most  ingenious  experiments,  he  showed  that 
cane-sugar  and  the  albumen  of  white  of  egg  must  pass  through  the  liver 
before  complete  assimilation  by  the  blood.  "When  these  substances  were 
injected  into  the  jugular  vein,  they  did  not  become  assimilated,  but  were 
discharged  in  the  urine.    No  such  discharge  took  place,  however,  when 


1878.]  Claude  Bernard  and  his  Physiological  Work 


167 


they  were  injected  into  the  portal  vein.  He  showed,  also,  that  it  was  not 
necessary  for  fats  to  pass  through  the  liver,  and  that  they  were  absorbed 
by  the  lacteals  and  became  directly  assimilated  by  the  blood.  As  the 
result  of  these  experiments,  he  concluded  that  the  chyle  is  not  to  be  con- 
sidered as  a  liquid  containing  all  of  the  nutritive  principles  resulting  from 
digestion,  as  had  been  the  almost  universally  adopted  opinion. 

The  two  volumes  of  lectures  published  by  Bernard  in  1859,  entitled 
Lemons  sur  les  preprietes  physiotogiqnes  et  les  alterations  pathologiques 
des  liquides  de  Vorganisme,  appeared  just  after  his  lectures  upon  the  ner- 
vous system,  which  latter  will  be  referred  to  in  another  connection.  These 
lectures  were  even  more  exhaustive  and  elaborate  than  those  upon  diges- 
tion. The  first  volume  was  devoted  to  a  consideration  of  the  blood.  In 
1853  he  had  published  a  memoir  on  the  capacity  of  the  blood  of  different 
parts  for  absorbing  oxygen,  containing  a  number  of  striking  experiments. 
In  the  volume  of  lectures  referred  to,  he  recited  a  large  number  of  exact 
observations  upon  the  temperature  of  the  blood  of  different  parts,  settling 
many  important  questions  that  had  before  been  undetermined.  His  gen- 
eral conclusions  from  these  experiments  was  that  the  seat  of  calorification 
of  the  blood  was  in  all  the  tissues  of  the  organism,  a  deduction  which  has 
been  fully  confirmed  by  subsequent  observations.  He  then  investigated 
the  differences  in  the  blood-pressure  in  different  vessels,  and  the  modifica- 
tions in  the  pressure  under  various  physiological  conditions,  the  influence 
of  the  nervous  system,  etc.  An  important  series  of  investigations  made 
in  this  connection  was  with  regard  to  the  influence  of  the  nervous  system 
upon  the.  colour  of  the  blood,  particularly  the  blood  coming  from  the  glands 
during  their  functional  activity  and  during  repose.  His  observations  upon 
the  colour  of  the  blood  coming  from  the  salivary  glands,  and  his  descrip- 
tion of  the  nervous  influence  over  the  activity  of  glands,  were  most  strik- 
ing, and  attracted  a  great  deal  of  attention.  For  example,  he  excited 
secretion  in  the  submaxillary  gland  by  stimulating  what  he  called  its 
motor  nerve,  and  the  venous  blood  from  the  gland  became  red.  By  stimu- 
lating another  nerve  he  arrested  the  secretion,  and  the  blood  from  the 
gland  became  dark. 

The  most  important  experiments,  however,  made  upon  the  blood  were 
those  in  which  he  determined  the  proportions  of  oxygen  by  the  method  of 
displacement  with  carbonic  oxide.  The  older  observations  of  Magnus  and 
others  had  been  very  contradictory  and  obscure  in  their  results.  Bernard 
showed  that  all  the  methods  of  analysis  of  the  blood  for  gases  which  in- 
volved a  delay  of  several  hours  before  the  results  could  be  ascertained 
were  faulty,  for  the  reason  that  oxygen  was  consumed  and  carbonic  acid 
produced  in  the  blood  after  it  had  been  drawn  from  the  body.  He  ascer- 
tained that,  by  agitating  the  blood  with  carbonic  oxide,  this  post-mor- 
tem consumption  of  the  oxygen  is  arrested;  and  he  obtained,  by  using 
carbonic  oxide  to  displace  the  oxygen,  the  actual  quantity  of  this  gas  con- 
tained in  the  blood  at  the  time  that  the  analysis  was  begun.  These  were 
the  first  experiments  which  gave  an  accurate  estimate  of  the  actual  propor- 
tion of  the  gases  existing  in  the  blood  under  different  physiological  condi- 
tions. They  also  showed  the  mechanism  of  poisoning  by  carbonic  oxide, 
and  illustrated  the  function  of  the  blood-corpuscles  as  oxygen-carriers. 
The  importance  of  these  facts  is  sufficiently  evident. 

In  the  second  volume  of  lectures  upon  the  liquids  of  the  organism,  Ber- 
nard very  clearly  and  distinctly  defined  the  differences  between  secretions 
and  excretions,  general  distinctions  which  have  hardly  met  with  the  atten- 


168 


Reviews. 


tion  at  the  hands  of  writers  upon  physiology  that  their  importance  and 
accuracy  merited.  I  pass  over  the  reiteration  of  his  views  upon  the 
properties  and  functions  of  the  digestive  fluids,  which  were  enforced  by 
additional  experiments,  and  come  to  his  researches  upon  the  mechanism 
of  secretion  and  excretion. 

In  1821  Prevost  and  Dumas,  who  demonstrated  the  accumulation  of 
urea  in  the  blood  following  extirpation  of  the  kidneys,  gave  to  practical 
physicians  the  first  definite  and  positive  basis  for  a  rational  pathology  of 
renal  diseases.  These  experiments  were  confirmed  and  somewhat  ex- 
tended by  other  observers  before  the  time  of  Bernard.  The  important 
fact  developed  by  the  researches  of  Prevost  and  Dumas  was  a  great  dis- 
covery ;  but  Bernard,  bringing  to  a  study  of  the  question  his  match- 
less ingenuity  and  dexterity  in  experimentation,  filled  many  of  the  gaps 
left  in  the  original  investigations.  lie  showed  the  vicarious  elimina- 
tion, for  a  time,  of  urea  by  the  stomach  and  intestines,  during  which  time 
there  is  no  accumulation  of  urea  in  the  blood,  following  extirpation  of  the 
kidneys  ;  and  he  demonstrated  that,  after  the  vicarious  elimination  of  urea 
has  ceased,  this  principle  produces  blood-poisoning.  His  experiments 
answer  most  completely  the  objections  which  were  subsequently  made  to 
the  idea  that  urea  is  formed  in  the  system  and  eliminated  by  the  kidneys, 
and  is  not  formed  in  the  kidneys,  by  Oppler,  Perls,  Zalesky,  and  others. 
In  short,  Bernard  settled  beyond  a  reasonable  doubt  the  doctrine  that  all 
the  excrementitious  principles  are  formed  in  the  system  at  large  by  the 
process  of  disassimilation,  and  are  eliminated  by  proper  organs. 

AVe  do  not  remember  that  any  physiologist,  before  Bernard,  enunciated 
definitely  and  positively  the  great  distinctions  between  secretions  and  ex- 
cretions, which  he  states  in  substance  as  follows  :  First,  that  the  produc- 
tion of  secretions  is  generally  intermittent,  while  the  production  of  excre- 
tions is  generally  constant ;  second,  that  the  elements  of  the  true  secretions 
do  not  pre-exist  in  the  blood,  but  are  formed  de  novo  in  the  glands  them- 
selves, while  the  elements  of  excretion  pre-exist  in  the  blood,  and  are  not 
formed  in  excreting  organs ;  third,  that  removal  of  secreting  glands  does 
not  cause  an  accumulation  of  the  elements  of  secretion  in  the  blood,  while 
removal  of  excreting  organs  is  followed  by  accumulation  of  excrementi- 
tious matters  in  the  blood  after  their  removal  by  vicarious  action  is  ar- 
rested ;  and,  finally,  that  secretions  have  important  functions  to  perform 
in  the  economy,  while  excretions  have  no  function  to  perform  and  are 
simply  separated  from  the  blood  to  be  discharged  from  the  body. 

In  the  same  volume  Bernard  took  up  again  the  question  of  the  influence 
of  special  nerves  over  the  salivary  secretions.  He  extended  his  observations 
by  a  variety  of  most  delicate  and  ingenious  experiments,  showing  the  in- 
fluence of  certain  nerves,  not  only  over  secretion  but  upon  the  blood-pres- 
sure, the  colour  of  the  venous  blood  coming  from  the  glands,  and  the  pro- 
portion of  oxygen  in  the  venous  blood  during  glandular  repose  and  activity. 
He  demonstrated  the  general  law  that,  during  the  so-called  repose  of  true 
secreting  organs,  the  cells  of  the  glands  are  forming  the  characteristic  ele- 
ments of  the  secretions  ;  that  when  the  secretion  is  discharged,  the  supply 
of  blood  sent  to  the  glands  is  largely  increased,  and  the  elements  of  the 
secretions  are  washed  out,  so  to  speak,  by  a  watery  transudation  and  are 
discharged  by  the  ducts.  This  law  gave  physiologists  an  idea  of  the  reason 
why  the  flow  of  true  secretions  cannot  be  constant,  a  certain  period  of  so- 
called  repose  being  necessary  for  the  formation  of  the  proper  elements  of 
secretion.    It  explained  the  fact  that  the  fluid  discharged  without  inter- 


1878.]  Claude  Bernard  and  his  Physiological  Works. 


169 


mission  from  a  permanent  pancreatic  fistula  is  not  normal  and  does  not 
possess  the  digestive  properties  of  the  true  pancreatic  juice,  for  the  reason 
that  no  interval  exists  for  the  formation  of  pancreatine  by  the  cells  of  the 
gland.  This  completely  answers  the  objections  made  by  certain  physio- 
logists to  the  conclusions  drawn  from  Bernard's  original  observations 
upon  the  pancreas. 

In  1857  Bernard  published  a  course  of  lectures  entitled  Lemons  stir  les 
ejfets  des  substances  toxiques  et  medicamenteuses.  These  lectures  were 
delivered  at  the  College  of  France  in  1856,  just  after  the  death  of  Ma- 
gendie,  his  illustrious  predecessor  in  the  chair  of  medicine.  The  first 
lecture  of  this  course  was  an  admirable  review  of  the  life  and  labours  of 
Magendie.  Bernard  had  been  his  prosector  and  assistant  for  many  years  ; 
he  had  supplied  his  place  in  the  lecture-room  ;  but  Magendie,  the  greatest 
physiologist  of  his  day,  the  discoverer  of  the  properties  of  the  roots  of  the 
spinal  nerves,  has  the  honour,  almost  as  great  as  any  achieved  by  his  own 
labours,  of  having  been  the  master  of  Claude  Bernard.  Bernard's  eulogy 
of  Magendie  was  a  modest  and  touching  tribute  of  one  great  man  to 
another  who  had  been  his  guide  and  model. 

In  his  lectures  upon  toxic  and  medicinal  substances,  Bernard  developed 
many  new  ideas  with  regard  to  the  action  of  deleterious  and  irrespirable 
gases,  and  showed  the  true  mechanism  of  death  from  inhalation  of  carbonic 
acid.  He  also  made  a  number  of  interesting  experiments,  entirely  novel  in 
their  character,  upon  the  tolerance  of  a  vitiated  atmosphere  by  animals 
slowly  and  gradually  subjected  to  its  action.  In  these  experiments,  he 
studied  the  action  of  carbonic  oxide  in  fixing  itself  in  the  blood-corpuscles, 
and  rendering  them  incapable  of  absorbing  oxygen  and  carrying  it  to  the 
tissues.  But  one  of  the  most  important  of  his  series  of  observations  re- 
lated to  the  effects  of  the  woorara  poison — called  by  the  French  curare. 
He  was  one  of  the  first,  if  not  the  first,  to  thoroughly  investigate  this 
remarkable  agent,  which  is  now  so  largely  used  in  physiological  investiga- 
tion, showing  its  peculiar  effects  upon  the  motor  system  of  nerves.  It  was 
by  experiments  with  woorara  that  Bernard  was  able  to  settle  definitively 
the  fact  of  the  mutual  independence  of  muscular  and  nervous  irritability. 

Many  of  the  most  important  discoveries  made  by  Bernard  relate  to  the 
physiology  of  the  nervous  system.  We  have  already  alluded  to  his 
researches  on  the  functions  of  the  chorda  tympani  nerve,  published  in  1843, 
from  which  his  brilliant  career  as  a  physiologist  may  be  dated.  We 
remember  well  a  conversation  with  Bernard  in  1861,  in  which  he  referred 
to  this  memoir.  His  young  friends,  internes  in  the  Paris  hospitals,  finding 
him  at  work,  asked  what  he  was  doing.  When  told  that  he  was  writing  a 
memoir  on  the  chorda  tympani,  they  showed  some  surprise  and  amuse- 
ment that  he  should  write  a  lengthy  paper  on  such  a  little  nerve.  Bernard 
related  with  much  humour  this  little  incident,  and  his  memoir  showed 
that  the  small  nerve  was  not  without  great  physiological  interest  and 
importance.  Bernard  did  few  small  things.  He  was  one  of  the  rare 
investigators  of  our  time  who  had  little  to  do  with  trivialities.  In  a 
social  and  amiable  way,  he  often  referred  to  a  class  of  physiologists  who 
contribute  to  literature  a  mass  of  little  things,  unimportant  in  themselves 
and  in  their  relations,  and  simply  showing  work.  "  Some  men,"  he  said, 
"  will  publish  minute  details  of  a  hundred  experiments,  ninety-nine  of 
which  are  failures,  and  they  seem  to  think  that  it  is  sufficient  to  do  work, 
although  they  may  really  accomplish  little  or  nothing."  We  know  of  no 
experiments  published  by  Bernard  that  are  not  intelligent,  useful,  and 


170 


Reviews. 


[July 


important.  He  was  not  fond  of  complicated  and  intricate  apparatus  ;  and 
lie  made  his  investigations  in  the  simplest  way,  so  that  most  of  his  experi- 
ments could  be  easily  repeated  by  a  practical  observer.  His  results  are 
an  illustration  of  the  fact  that  an  imposing  laboratory  and  complex 
machinery  for  investigation  do  not  of  necessity  make  the  greatest  physiol- 
ogists or  lead  to  the  most  important  discoveries. 

One  of  the  most  remarkable  errors  made  by  Bernard  in  his  earlier 
writings  upon  the  nervous  system  was  that  he  ascribed  the  discovery  of  the 
distinct  properties  of  the  roots  of  the  spinal  nerves  to  Sir  Charles  Bell, 
and  characterized  the  observations  of  Magendie  as  simply  confirmatory.  His 
two  volumes  of  Lectures  on  the  Nervous  System,  published  in  1858, 
embody  his  views  and  discoveries  up  to  the  date  of  publication.  In  the 
first  volume  he  says  :  "  Charles  Bell  had  indicated  by  induction,  about 
the  beginning  of  this  century,  that  the  posterior  roots  should  be  sensitive 
and  the  anterior  roots  motor.  AVe  know  that  later  Magendie  found,  by 
dividing  separately  one  and  the  other,  that,  upon  this  point,  the  views  of 
Charles  Bell  were  exact."  It  was  not  until  1867,  ten  years  later,  in 
his  report  on  the  progress  of  physiology  in  France,  that  he  rendered 
full  justice  to  Magendie,  who  was  the  real  discoverer  of  the  properties  of 
the  roots  of  the  spinal  nerves  in  1822.  In  this  report  Bernard  says: 
"In  1811,  then,  Charles  Bell  did  not  know  the  functions  of  the  roots 
of  the  spinal  nerves;  he  falsely  interpreted  a  fact  which  it  has  been  desired 
later  to  allege  in  his  favour." 

It  is  certain  that  Bernard  did  not  intend  or  desire  to  deprive  Magendie 
of  the  credit  of  any  discovery  ;  and  it  must  be  remembered  that  Sir 
Charles  Bell's  pamphlet,  entitled  An  Idea  of  a  New  Anatomy  of  the 
Brain,  was  not  accessible,  and  was  known  only  through  extracts  and  an 
obscure  republication  which  appeared  anonymously  in  1839.  During  a 
certain  period  of  his  physiological  career,  Bernard  was  more  occupied  in 
making  than  in  studying  physiological  literature,  and  he  had  little  or  no 
knowledge  of  the  English  language.  Nearly  all  of  his  works,  particularly 
those  of  early  date,  were  full  of  original  research  and  contained  little  in 
the  way  of  historical  discussion.  His  later  writings,  however,  showed 
more  of  a  tendency  to  generalization ;  but  he  still  dealt  largely  with  facts 
that  he  had  developed  by  his  own  researches. 

Those  who  are  interested  in  the  history  of  what  is  termed  nerve-physi- 
ology, which  is  so  much  studied  at  the  present  day,  will  find,  in  the  first 
volume  of  Bernard's  lectures  on  the  nervous  system,  published  in  1858, 
most  elaborate  and  interesting  researches  on  the  phenomena  developed  by 
the  application  of  galvanic  currents  to  the  nerves.  In  this  volume  he  also 
made  some  important  additions  to  our  knowledge  of  reflex  action. 

The  second  volume  of  the  lectures  on  the  nervous  system,  published  in 
1858,  embodies  nearly  all  of  Bernard's  discoveries  with  regard  to  the 
functions  of  special  nerves.  The  same  ingenuity  in  devising  experiments 
to  settle  disputed  questions  and  develop  new  facts  is  observed  in  this  as 
in  his  other  writings.  He  devised  a  method  of  cutting  the  facial  in  the 
case  of  the  tympanum,  and  noted  the  effects  upon  animals  of  intracranial 
and  extracranial  section  of  this  nerve.  He  took  up  Magendie's  operation 
of  intracranial  division  of  the  large  root  of  the  fifth  nerve,  and  studied 
most  accurately  the  effects  of  its  section  before  and  after  it  had  received 
its  communicating  filaments  from  the  sympathetic.  He  made  a  number 
of  most  interesting  experiments,  also,  upon  the  motor  nerves  of  the  eye, 
and  showed  the  influence  of  the  third  nerve  upon  the  movements  of  the  iris. 


1878.]  Claude  Bernard  and  his  Physiological  Works. 


171 


We  have  already  briefly  referred  to  the  memoir  upon  the  functions  of 
the  spinal  accessory  nerve,  originally  published  in  1844.  In  1832  Bis- 
ehoff  published  a  series  of  experiments  upon  goats,  in  one  of  which,  having 
divided  all  the  roots  of  the  spinal  accessory  on  both  sides,  with  extensive 
exposure  of  the  parts  which  greatly  exhausted  the  animal,  he  found  that 
the  sound  emitted  by  the  larynx  "  was  one  which  could  in  no  wise  be  called 
voice."  This  experiment,  however,  was  very  unsatisfactory,  and  attracted 
but  little  attention.  Before  the  publication  of  Bernard's  memoir,  it  was 
generally  held  by  physiologists  that  the  recurrent  laryngeal  branches  of 
the  pneumogastrics  were  the  nerves  of  phonation. 

One  of  the  greatest  merits  of  Bernard's  observations  upon  the  spinal 
accessory  was  the  method  which  he  employed  for  extirpation  of  the  nerve. 
The  difficulty  had  been,  in  the  experiments  of  Bischoff,  to  divide  all  of  the 
roots  without  such  a  shock  to  the  animal  and  excessive  loss  of  blood  as  to 
render  very  unsatisfactory  any  observations  after  the  section  had  been 
made.  It  will  be  remembered  that  the  extensive  origin  of  the  nerves  from 
the  medulla  oblongata  and  the  cervical  portion  of  the  spinal  cord  had  appa- 
rently rendered  it  necessary  to  open  a  large  portion  of  the  spinal  canal. 
Bernard  attempted  to  do  this  after  BischofPs  method,  but  without  satisfac- 
tory results.  He  then  devised  the  method  of  removing  the  nerve  by 
avulsion.  He  cut  down  upon  the  muscular  branch  as  it  passes  through  the 
sterno-cleido-mastoid  muscle,  followed  up  the  nerve  by  careful  dissection 
as  far  as  the  posterior  foramen  lacerum,  seized  the  trunk  as  it  emerges  from 
the  foramen  with  broad-billed  forceps,  including  the  communicating  branch 
to  the  pneumogastric,  and  then,  by  gentle,  firm,  and  steady  traction,  he 
pulled  out  the  entire  nerve  by  the  roots.  These  experiments  he  performed 
upon  young  cats,  dogs,  and  guinea-pigs.  When  both  nerves  were  com- 
pletely extirpated  in  this  way,  the  voice  was  abolished,  while  the  respira- 
tory movements  of  the  larynx  were  not  affected.  Extirpation  of  one 
nerve  rendered  the  voice  hoarse.  Extending  his  experiments  still  further, 
he  showed  that  the  filaments  which  preside  over  the  vocal  movements  of 
the  larynx  come  from  the  roots  originating  at  the  medulla  oblongata,  and 
that  the  roots  from  the  spinal  cord  send  their  filaments  to  the  muscular 
branch.  By  these  most  simple  and  satisfactory  experiments,  it  was  defi- 
nitely ascertained  that  the  innervation  of  the  larynx  is  double  ;  that  the 
nerve  which  animates  the  muscles  concerned  in  modifying  the  tension  of 
the  vocal  cords  is  the  spinal  accessory,  the  filaments  of  which  go  to  the 
pneumogastric  by  the  communicating  branch  and  pass  to  the  larynx 
through  the  recurrent  laryngeals  ;  and  that  the  filaments  of  the  recurrent 
laryngeals  which  preside  over  the  ordinary  respiratory  movements  of  the 
larynx  are  derived  from  other  motor  communications  of  the  pneumogas- 
tric, and  not  from  the  spinal  accessory. 

In  the  same  volume  of  lectures,  Bernard  recites  a  number  of  interesting 
and  original  experiments  upon  the  pneumogastric  nerves  and  their  various 
branches. 

We  now  come  to  a  discovery  with  regard  to  the  nervous  system  which 
has,  perhaps,  been  more  extended  by  subsequent  observations  than  any 
other  that  we  have  mentioned.  We  refer  to  Bernard's  observations  upon 
the  nerves  of  the  so-called  sympathetic  system. 

In  1816  Dupuy  removed  the  superior  cervical  sympathetic  ganglion  in 
horses,  and  noted  vascular  injection  of  the  conjunctiva,  increase  of  tem- 
perature in  the  ear,  and  an  abundant  secretion  of  sweat  upon  the  side  of  the 
head  and  neck  corresponding  to  the  section.    In  the  Gomptes  Rendus  de  la 


172 


Reviews. 


[July 


Societe  de  Biologie,  Paris,  1851,  tome  iii,  page  163,  Bernard  reported  a 
series  of  experiments  upon  rabbits,  in  which  he  divided  the  sympathetic  in 
the  neck  upon  one  side,  and  noted,  on  the  corresponding  side  of  the  head 
and  the  ear,  increased  vascularity,  and  an  elevation  in  temperature,  amount- 
ing to  from  7°  to  11°  Fahr.  This  condition  of  increased  heat  and  vascu- 
larity was  sometimes  observed  for  several  months  after  division  of  the 
nerve.  Brown-Sequard  repeated  and  extended  these  observations  very 
soon  after ;  but  we  cannot  find  that  his  experiments  were  published  before 
they  appeared  in  The  Medical  Examiner,  Philadelphia,  August,  1852. 
The  experiments  of  Dupuy  attracted  very  little  attention.  Valentin 
made  a  reference  to  filaments  of  the  sympathetic  distributed  to  the  blood- 
vessels and  influencing  their  calibre,  in  1839.  We  regard  Bernard  as 
the  discoverer  of  the  vaso-motor  system  of  nerves  ;  and  it  is  certain  that 
the  publication  of  his  experiments  antedated  the  appearance  of  Brown- 
Sequard's  observations  by  about  one  year.  We  hardly  need  discuss  the 
great  importance  of  this  discovery,  showing,  as  it  does,  the  influence  of 
the  sympathetic  upon  the  supply  of  blood  to  parts,  calorification,  and  nutri- 
tion, nor  shall  we  refer  in  detail  to  the  facts  that  have  been  developed  by 
others  as  a  consequence  of  the  experiments  of  Bernard.  The  observations 
published  in  1851  were  the  real  starting-point  of  our  present  knowledge 
of  the  functions  of  the  sympathetic  system. 

The  two  volumes  of  lectures  on  the  Liquids  of  the  Organism  were  pub- 
lished in  1859.  From  that  time  until  18G5,  when  a  volume  of  lectures 
appeared,  entitled  Introduction  a  Vetude  de  la  medecine  experimentale,  the 
literary  labours  of  Bernard  were  confined  mainly  to  articles  in  the  Journal 
de  la  physiologic,  the  publication  of  which  began  in  1858.  To  this  Jour- 
nal, which  was  continued  as  the  Journal  de  Vanatomie  et  de  la  physiolo- 
gie  after  1864,  Bernard  contributed  numerous  original  papers.  In  1863 
there  appeared  the  first  number  of  the  Revue  des  cours  scientijiques,  which 
was  continued  after  1871  as  the  Revue  scientijique.  The  editors  of  the 
Revue  published  the  lectures  of  Bernard  as  they  were  delivered,  and  the 
last  appeared  after  his  death.  The  most  important  of  these  lectures  were 
afterward  collected  and  published  as  separate  volumes.  The  Introduction 
a  Vetude  de  la  medecine  experimentale,  published  in  1865,  was  followed,  in 
1866,  by  the  Lemons  sur  les  proprieties  des  tissns  vivants;  this,  by  the 
Lecons  de  pathologic  experimental  e,  published  in  1872  ;  this,  by  the  Lecons 
sur  les  anesthetiques  et  sur  Vasphyxie,  published  in  1875  ,  this,  by  the 
Lemons  sur  la  chaleur  animate,  published  in  1876  ;  this,  by  the  Lemons  sur 
la  diabete  et  la  glycogenese  animate,  published  in  1877  ;  and  finally,  just 
after  the  death  of  the  author  (1878),  two  volumes  have  appeared,  one 
entitled  La  science  experimentale,  and  the  other,  Lemons  sur  les phenomenes 
de  la  vie. 

A  full  analysis  of  the  original  contributions  of  Bernard  to  physiological 
literature  wrould  extend  itself  nearly  to  the  dimensions  and  scope  of  a  sys- 
tematic treatise.  There  are  few  subjects  connected  with  physiology  that 
do  not  bear  the  impress  of  his  labours.  His  memoirs  and  lectures  up  to 
1859  were  mainly  original,  and  they  contained  little  in  the  way  of  gene- 
ralities, although  he  prefaced  nearly  all  of  his  volumes  with  an  exposition 
of  the  experimental  method.  After  1865  the  character  of  his  thoughts  and 
studies  seems  to  have  changed.  While  he  constantly  reiterated  his  origi- 
nal views  and  extended  his  observations  in  the  directions  opened  by  his 
own  discoveries,  he  devoted  more  attention  to  generalization  and  to  the 
results  of  the  labours  of  others.    His  method,  which  was  rigidly  experi- 


1878.]  Claude  Bernard  and  his  Physiological  Works. 


173 


mental  and  deductive,  he  constantly  advocated,  and  the  labours  of  his  pupils 
in  France  and  elsewhere  have  borne  testimony  to  the  good  effects  of  his 
precepts  and  example.  It  may  not  be  out  of  place  to  refer  here  to  the  influ- 
ence which  his  works  have  exerted  upon  physiology  in  this  country.  In 
1851  Prof.  Dalton  gave  a  short  course  of  lectures  upon  experimental 
physiology  to  the  students  of  the  Boylston  Medical  School  in  Boston. 
The  same  year  (1851-1852)  he  gave  a  course  at  the  Buffalo  Medical 
College,  illustrated  by  experiments  upon  living  animals  ;  and  in  1852  he 
attended  Bernard's  lectures  at  the  College  of  France.  Since  1855  he 
has  lectured  upon  physiology  in  the  same  way  in  New  York,  and  others 
have  followed  his  example.  We  venture  to  say  that  demonstrative  teach- 
ing in  physiology  in  this  country  is  to  be  attributed  to  the  influence  of 
Bernard's  works,  to  say  nothing  of  the  original  investigations  which  have 
given  our  own  observers  a  more  than  respectable  position  in  physiological 
literature.  The  only  publication,  however,  which  has  appeared  here,  to 
which  Bernard's  name  is  attached,  is  a  little  book  of  Notes  of  M.  Ber- 
nard's Lectures  on  the  Blood,  by  Walter  F.  Atlee,  M.D.,  published  in 
Philadelphia,  in  1854. 

The  smallest  of  Bernard's  titles  to  fame  were  the  titular  and  other 
honours  that  were  bestowed  upon  him  in  the  course  of  his  remarkable 
career.  About  1841,  before  he  received  the  degree  of  Doctor  of  Medicine, 
lie  was  attached  to  the  laboratory  of  Magendie  as  assistant  and  prosector. 
In  1843  he  took  his  degree  in  Medicine,  In  1853  he  was  admitted  a 
Doctor  of  Sciences;  and  the  chair. of  general  physiology  was  created  for 
him  in  the  Faculty  of  Sciences  at  the  Sorbonne.  From  1847  to  1855  he 
acted  as  professeur  suppliant  to  Magendie  at  the  College  of  France,  and 
in  1855  he  succeeded  Magendie  as  Professor  of  Medicine.  In  1868  he 
was  appointed  Professor  at  the  Museum  of  Natural  History.  He  was 
elected  a  member  of  the  Academy  of  Medicine  in  1861,  perpetual  presi- 
dent of  the  Society  of  Biology  in  1867,  and  a  member  of  the  Institute  of 
France  in  1869.  In  1867  he  was  appointed  commander  in  the  Legion  of 
Honour,  and  in  1869  Senator  of  France.  At  the  time  of  his  death  he 
was  a  member  of  most  of  the  learned  societies  of  Europe. 

It  has  been  a  peculiarly  agreeable  task  for  us  to  attempt  to  follow  the 
scientific  career  of  the  great  physiologist  whose  labours  are  now  ended;  and 
we  have  often  found  it  difficult  to  restrain  our  enthusiasm  within  the  limits 
that  we  had  fixed,  for  we  intended  to  write  a  simple  analytical  review  of 
his  most  important  works.  We  shall  not  compare  him  with  his  contem- 
poraries or  with  the  other  great  discoverers  whose  names  we  revere  and 
honour.  He  was  a  simple  searcher  after  truth ;  and  his  thirty -five  years 
of  labour  in  physiology  have  brought  forth  more  fruit  and  have  done  more 
for  humanity  than  any  one  now  living  can  hope  to  accomplish.  His  dis- 
ciples may  feel  proud  that  they  are  permitted  to  continue  their  work  as 
followers  of  Claude  Bernard. 

Many  of  the  writings  of  Bernard  are  published  as  separate  memoirs^  which  are 
difficult  of  access,  and  as  contributions  to  periodicals ;  but  all  of  his  discoveries 
and  his  most  important  reflections  upon  physiological  subjects  will  be  found  in  the 
following  works,  which  are  enumerated  in  the  order  of  their  publication : — 

Legons  de  pliysiologie  experimentale,  1855. 

Legons  de  pliysiologie  experimentale,  tome  deuxieme,  1856. 

Legons  sur  les  effets  des  substances  toxiques  et  me'dicamenteuses,  1857. 

Legons  sur  la  physiologie  et  la  pathologie  du  systeme  nerveux,  2  vols.,  1858. 

Legons  sur  les  propriete's  physiologiques  et  les  alterations  pathologiques  des 
liquides  de  I'organisme,  2  vols.,  1859. 


174 


Reviews  . 


[July 


Introduction  &  l*4tude  de  la  medecine  exp6rimentale,  1865. 

Legons  sur  les  propriiUs  des  tissus  vivants,  1866. 

Legons  de  pathologic  experimental  e,  1872. 

Legons  sur  les  anesthetiques  et  sur  V asphyxie,  1875. 

Legons  sur  la  chaleur  animate  et  sur  les  ejf'ets  de  la  chaleur,  1876. 

Legons  sur  le  diabete  et  la  glycogenese  animate,  1877. 

Legons  sur  les  ph6nomenes  de  la  vie,  1878. 

La  science  experimental,  1878. 

The  volume  entitled  La  science  experimental  is  a  collection  of  memoirs  and 
addresses  upon  different  subjects  connected  with  physiology,  from  1844  to  1876. 
The  subjects  are  as  follows  :  Progres  des  sciences  physiologiques  ;  Problemes  de 
la  physiologie  generale  ;  La  vie,  les  theories  anciennes  et  la  science  moderne ;  La 
chaleur  animale;  La  sensibility ;  Le  curare;  Lecoeur;  Le  cerveau  ;  Discours  de 
reception  a  V  Academic  francaise.  A.  F.,  Jr. 


Art.  XVIII. — Higher  Medical  Education. 

1.  Practical  Essays  on  Medical  Education  and  the  Medical  Profession 
in  the  United  States.  By  Daniel  Drake,  M.D.,  Cincinnati,  1832. 
8vo. 

2.  Lectures  on  Medical  Education.  By  Samuel  Chew,  M.D.,  Phila- 
delphia, 18G4.  8vo. 

3.  Contributions  to  the  History  of  Medical  Education  and  Medical 
Institutions  in  the  United  States  of  America,  177G-187G.  Bv  N. 
S.  Davis,  A.M.,  M.D.,  Washington,  1877.  8vo. 

4.  Higher  Medical  Education,  the  True  Interest  of  the  Public  and  the 
Profession.  An  Address  Introductory  to  the  \\2th  Course  of  Lec- 
tures in  the  Medical  Department  of  the  University  of  Pennsylvania. 
By  William  Pepper,  A.M.,  M.D.  Philadelphia  :  J.  B.  Lippin- 
cott  &  Co.,  1877.  8vo. 

5.  De  V organisation  des  Facultes  de  Medecine  en  Allemagne.  Par  le 
docteur  Jaccoud,  Paris,  1864.  8vo. 

6.  Les  hautes  etudes  pratiques  dans  les  Universites  Allemandes.  Par 
Adolphe  Wurtz,  Paris,  1870.  4to. 

7.  Etude  sur  V organisation  de  la  Medecine  en  France  et  a  Vetranger. 
Par  Leon  Le  Fort,  Paris,  1874.  8vo. 

8.  Ueber  das  Lehren  und  Lemen  die  Medicinischen  Wisoenschaften  an 
den  Universit'dten  der  Deutschen  Nation.  Von  Dr.  Th.  Billroth, 
Wien,  1876.  8vo. 

9.  L'enseignement  de  la  Medecine  en  Allemagne.  Par  Louis  Fiaux, 
Paris,  1877.  8vo. 

10.  De  la.  situation  de  V enseignement  Medical  en  France.  Par  Chauf- 
fard,  Kev.  des  Deux  Mondes,  Jan.  1,  1878. 

11.  Medical  Politics;  being  the  Essay  to  ichich  ivas  awarded  the  first 
Carmichael  Prize,  1873.  By  Isaac  Ashe,  M.D.  (etc.),  Dublin, 
1875.  8vo. 

12.  Report  of  Proceedings  of  the  Meeting  of  the  General  Medical  Coun- 
cil in  1877.    Med.  Times  and  Gaz.,  May  and  June,  1877. 

It  has  been  observed  that  the  difficulty  in  forming  an  opinion  on  a  sub- 
ject is  materially  increased  by  studying  it,  and,  as  regards  medical  educa- 
tion, this  statement  is  certainly  correct.  We  have  had  occasion  to 
examine  with  care  the  publications  whose  titles  head  this  article,  and  have 


1878.] 


Higher  Medical  Education. 


175 


also,  -with  somewhat  less  care,  glanced  over  about  a  hundred  other  essays 
and  addresses  on  the  same  subject,  and  the  result  is  that  we  have  no  plan 
at  present  which  can  be  recommended  as  a  certain  cure  for  the  evils  com- 
plained of.  Having  made  this  confession  of  ignorance,  Ave  now  propose 
to  set  forth  some  of  the  plans  of  others  who  have  been  more  fortunate. 

No  critical  review  of  the  works  mentioned  will  be  attempted;  those 
who  are  interested  in  the  subject  are  advised  to  read  all  of  them  ;  we  shall 
give  but  a  brief  resume,  with  an  occasional  comment  or  query. 

There  may  have  been  a  time  when  the  physicians  of  some  favoured 
country  were  entirely  satisfied  with  each  other's  professional  skill ;  but 
the  records  of  that  period  have  been  lost.  Hippocrates,  Galen,  Van  Hel- 
mont,  and  Sydenham  speak  of  contemporaneous  physicians  in  much  the 
same  tone  as  that  in  winch  English,  French,  German,  and  American 
writers  have  been  for  fifty  years,  and  are  to-day,  commenting  on  the  re- 
sults of  their  systems  of  medical  education. 

So  long  as  this  complaining  does  not  pass  the  limits  of  what  may  be 
called  grumbling,  proceeding  mainly  from  those  who  are  out  of  the  race, 
or  who  may  be  reasonably  suspected  of  being  misled  by  the  idea  that  their 
own  powers  and  qualifications  have  been  overlooked,  it  may  be  allowed  to 
pass  without  much  notice  :  but  when  it  becomes  general ;  when  in  one 
particular  country  we  hear  it  from  students,  teachers,  and  from  private 
physicians  generally ;  and  when  we  find  that  the  grumblers  of  other  na- 
tions, always  ready  to  disparage  what  they  themselves  possess,  and  to 
draw  unfavourable  contrasts  between  their  systems  and  those  of  other 
countries,  make  an  exception  with  regard  to  that  particular  country,  we 
may  infer  that  there  is  really  something  wrong  in  that  case.  Now  this 
seems  to  be  the  condition  of  things  with  regard  to  medical  education  in 
the  United  States  at  the  present  time.  Every  one  here  seems  dissatisfied ; 
and  abroad,  while  English  writers  are  pointing  out  the  superiority  of  the 
French  or  German  systems,  and  French  writers  demanding  less  central- 
ization on  the  English  plan,  we  nowhere  find  the  system  of  the  United 
States  held  up  as  a  model. 

This  may  be  considered  as  being,  upon  the  whole,  a  good  sign,  since 
the  first  step  towards  improvement  is  the  recognition  of  the  evil  to  be 
done  away  with ;  but  in  the  United  States  familiarity  seems  to  have  bred 
contempt  in  several  senses.  Of  the  causes  for  this  state  of  things  we  need 
mention  but  a  few. 

The  first  is  the  character  of  medical  students,  and  the  motives  which 
induce  many  to  enter  the  profession.    As  Dr.  Drake  puts  it : — 

"  A  neighbouring  physician  wants  a  student  to  reside  in  his  office,  or  one  son 
of  the  family  is  thought  too  weakly  to  labour  on  the  farm  or  in  the  workshop  ; 
he  is  indolent  and  averse  to  bodily  exertion,  or  addicted  to  study,  but  too  stupid 
for  the  bar.  or  too  immoral  for  the  pulpit ;  the  parents  wish  to  have  one  gentleman 
in  the  family,  and  a  doctor  is  a  gentleman ;  these  and  many  other  extraneous 
considerations  not  unfrequently  decide  the  choice  and  swell  the  numbers,  while 
they  impair  the  character  of  the  profession." 

The  principal  motive  for  the  study  of  medicine  is  not  the  love  of  science 
or  of  humanity;  but,  as  Dr.  Pepper  points  out,  "a  desire  to  earn  an 
honest  livelihood."  It  is  a  matter  of  business,  nnd  it  is  natural  that  the 
young,  inexperienced,  and  usually  poor  aspirant  should  think  that  the  less 
capital  required  to  obtain  the  absolutely  necessary  stock  in  trade,  the  bet- 
ter for  his  purpose.  Hence  the  tendency  is  towards  the  minimum  quali- 
fication— the  current  sets  in  the  direction  of  the  easiest  outlet. 


176 


Reviews. 


[July 


The  second  cause  is,  that  a  thorough  education  is  not  as  essential  to 
success  in  the  medical  as  in  other  professions,  nor  does  its  possession  in- 
sure success  in  the  same  ratio.  Physicians  are  not  selected  by  the  public 
with  reference  to  their  education  ;  in  fact,  the  public  are  not  competent  to 
judge,  and  the  fashionable  doctor  is  by  no  means  always  superior  in  knowl- 
edge. Medical  students  soon  learn  this,  and  are  apt  to  conclude  that 
thorough  knowledge  is  not  as  desirable  in  a  business  point  of  view  as  it 
really  is. 

A  third  cause  of  trouble  is,  that  too  much  is  demanded  of  the  average 
student,  and  he  is  forced  to  be  superficial  in  his  acquirements  in  self- 
defence. 

The  average  student  wishes  to  be  a  practitioner  of  medicine,  to  know  a 
pneumonia,  or  a  typhoid  fever,  or  a  dislocated  shoulder  when  he  sees  it, 
and  to  know  how  physicians  usually  treat  such  cases.  He  does  not  intend 
to  go  into  the  wilderness,  but  to  be  near  other  physicians  upon  whom  he 
can  call  in  a  doubtful  case ;  he  has  no  desire  to  be  a  medical  expert  or  a 
sanitarian,  or  a  specialist  of  any  kind,  nor  yet  to  make  discoveries  or  con- 
tribute to  medical  literature.  He  knows  what  he  most  needs  for  his  pur- 
poses, i.  e.,  clinical  and  therapeutical  instruction  ;  he  wants  to  see  cases, 
and,  as  far  as  possible,  the  kind  of  cases  he  expects  to  treat.  The  anatomy 
which  interests  him  is  that  of  the  arteries  ;  for  more  than  the  broad  gen- 
eral principles  of  physiology  he  cares  little;  he  likes  his  therapeutics  neatly 
packed  in  formula?,  and  as  for  the  languages  and  natural  sciences,  he  sees 
very  little  use  in  their  study.  To  such  a  man  the  majority  of  the  de- 
mands for  a  higher  and  better  medical  education  seem  unreasonable  ;  he 
does  not  aspire  to  a  position  which  requires  such  an  expenditure  of  time 
and  money  to  fit  one  to  fill  it. 

The  majority  of  authors  and  essayists  consider  medical  education  solely 
as  designed  to  fit  men  to  exercise  the  art  or  handicraft  of  medicine,  and 
therefore  consider  that  as  the  best  system  which  produces  the  best  prac- 
titioners. Now  it  needs  but  little  reflection  to  see  that  all  medical  prac- 
titioners cannot  be  alike  skilful  and  accomplished.  The  doctor  and  the 
qfficier  de  scinte  of  France  represent  two  great  classes  of  medical  men ; 
classes  which  must  always  exist,  whether  they  be  distinguished  by  title 
or  not. 

Professional  skill,  like  all  skilled  labour,  has  a  market  value,  and  will 
be  found  where  that  value  is  given  for  it.  Nor  is  the  remuneration  en- 
tirely a  matter  of  money.  The  thoroughly  educated  physician  requires  an 
atmosphere  of  appreciation  and  encouragement,  congenial  society,  and 
many  other  things  which  he  will  not  find  in  thinly  settled  and  compara- 
tively poor  districts. 

These  districts  must,  however,  have  physicians,  and  these  physicians 
must  be  mainly  routine-practitioners.  In  the  education  of  such  men  the 
most  important  thing  is  the  study  of  the  disease  on  the  living  subject. 
They  are  almost  all  poor  men,  poor  in  time  as  well  as  money;  they  cannot 
have  that  sort  of  preliminary  education  contemplated  by  the  requirement 
of  the  Baccalaureate  Degree.  This  must  be  taken  into  consideration  in 
planning  their  curriculum.  They  will  never  learn  chemistry,  geology, 
physiology,  and  pathology,  but  they  may  learn  how  to  treat  fever,  frac- 
tures, and  wounds,  how  to  tie  an  artery,  to  apply  the  obstetric  forceps, 
and  to  use  quinia,  opium,  and  a  dozen  other  drugs.  There  must  be  a 
minimum  standard  of  knowledge  fixed  for  them  ;  and  it  must  be  fixed, 
not  with  reference  to  what  a  man  who  is  to  meddle  with  that  complicated 


1878.] 


Higher  Medical  Education. 


177 


machine — the  human  body — should  know,  but  with  reference  to  the  de- 
mands of  society  as  measured  by  the  value  placed  upon  the  services  ren- 
dered. 

We  have  said  that  all  authors  are  dissatisfied  with  existing  systems  of 
medical  education,  and  demand  something  higher  and  better,  but  they  do 
not  all  use  the  same  words  in  the  same  sense.  American  and  English 
writers  mean  by  higher  medical  education  that  the  average  education  of 
the  practitioner  is  to  be  raised,  he  is  to  study  longer,  and  more  branches, 
and  to  have  a  more  severe  examination.  But  French  and  German  writers 
mean  also  by  higher  medical  education  that  original  research  should  be 
encouraged,  that  the  science  and  art  of  medicine  should  be  improved,  that 
to  the  student  should  be  imparted  not  only  existing  knowledge,  but  the 
desire  and  the  power  to  add  to  it. 

Assuming  the  superiority  of  the  German  Universities,  Prof.  Billroth 
thinks  that  it  is  due  to  the  fact  that  they  combine  the  functions  of  a 
school  and  of  a  learned  society.  It  is  the  duty  of  the  German  professor 
not  only  to  know  the  latest  advances  in  science  and  to  teach  them,  but 
also  to  become  himself  an  investigator  in,  and  an  improver  of,  that  branch 
which  he  is  to  teach.  The  result  is  that  his  teaching  partakes  of  this 
spirit  of  inquiry,  and  his  pupils,  or  at  least  the  best  of  them,  are  trained 
in  this  spirit  and  method,  and  can  often  materially  assist  the  teacher  while 
improving  themselves.  That  there  are  certain  dangers  in  this  he  sees 
clearly  enough.  He  points  out  that  the  government  lias  the  right  to  de- 
mand that  the  people  shall  be  supplied  with  competent  and  trustworthy 
physicians,  and  as  it  is  the  business  of  the  universities  to  produce  these, 
they  must  not  let  the  society  predominate  over  the  school  in  their  method 
of  work. 

As  far  as  the  school  functions  only  are  concerned  we  have  indicated 
some  of  the  causes  which  are  constantly,  in  all  countries,  tending  to  make 
the  education  and  qualifications  of  the  average  physician  lower  than  they 
should  be.  But  as  the  character  and  skill  of  his  nearest  physician  may 
be  at  some  time  a  matter  of  the  gravest  importance  to  any  man,  be  he  rich 
or  poor,  it  is  not  surprising  that  attempts  should  be  made  to  resist  this 
tendency.    Professor  Le  Fort  remarks  that — 

''The  theory  which  in  all  European  nations  has  governed  the  organization  of 
the  medical  profession  is  this  :  As  the  State  is  morally  bound  to  protect  the  health 
and  lite  of  its  citizens,  and  as  these  cannot  know  whether  a  certain  individual  has 
sufficient  knowledge  to  practise  medicine  with  safety  to  his  patients,  the  State 
bestows  certain  titles  upon,  and  marks,  as  it  were,  with  the  seal  of  its  guarantee, 
those  whom  it  presents  to  its  citizens  as  worthy  of  their  confidence.  The  United 
States  of  America  alone  forms  an  exception  to  this  rule." 

This  same  theory,  as  De  Morgan  points  out,  was  once  applied  to  the  souls 
of  the  citizens  as  well  as  to  their  bodies,  and  it  cannot  be  considered  incon- 
trovertible ;  but  we  will  consider  this  hereafter.  Let  us  now  see  how  the 
theory  is  carried  out  in  three  or  four  of  the  principal  European  countries. 

In  Austria  the  diploma  of  Doctor  of  Medicine  from  any  Austrian  uni- 
versity gives  to  its  holders  the  right  to  practise  throughout  the  empire, — a 
privilege  formerly  held  by  the  Vienna  University  alone.  The  preliminary 
examination  of  the  student  is  in  botany,  zoology,  and  mineralogy,  and  the 
certificate  of  graduation  from  a  gymnasium1  or  high  school  is  also  required. 

1  The  course  of  study  at  the  gymnasium  occupies  eight  years,  and  includes  Latin, 
Greek,  German,  geography,  history,  botany,  zoology,  mineralogy,  logic,  and  psychology. 
In  addition  to  these,  the  following  are  taught,  but  their  study  is  not  obligatory,  viz.  : 
modern  languages,  drawing,  singing,  and  stenography. 

No.  CLI  July  1878.  12 


178 


Reviews. 


[July 


It  is  usually  passed  about  tAvo  years  after  matriculation,  but  may  be  passed 
at  any  time  of  the  first  four  weeks  of  any  semester.  The  examination 
for  the  degree  of  Doctor  of  Medicine  is  divided  into  three  parts,  known 
as  the  three  rigorosa. 

To  be  admitted  to  the  first  rigorosum  the  requirements  are,  certificates 
of  birth,  baptism,  and  gymnasial  graduation,  of  two  years'  attendance  at  the 
university,  with  at  least  ten  lectures  per  week,  of  having  dissected  for  one 
year,  and  of  having  passed  the  preliminary  examination.  For  the  second 
and  third  rigorosa  there  are  required,  certificates  of  faculty  attendance  for 
five  years,  of  two  years'  attendance  on  medical  and  surgical  clinics,  of  one- 
half  year's  clinical  study  of  obstetrics  and  ophthalmology,  and  of  having 
passed  the  first  rigorosum,. 

The  peculiarities  of  the  medical  institutions  of  Germany  are  largely 
due  to  the  fact  that,  in  the  latter  part  of  the  seventeenth  century,  the 
government  established  a  network  of  medical  officials  over  the  country, 
and  organized  its  own  boards  of  examination  for  those  who  desired  to  be- 
come practising  physicians,  which  boards  were  independent  of  the  univer- 
sities.1 This  system  was  intended  to  secure  the  best  medical  talent  for 
the  service  of  the  government,  but  the  result  was  not  very  satisfactory, 
and  it  was  found  difficult  to  obtain  a  sufficient  supply  of  skilled  medical 
men  for  the  military  service;  and  in  Austria,  Saxony,  Prussia,  and  Russia, 
schools  were  established  at  the  end  of  the  eighteenth  century  for  the  pur- 
pose of  educating  army  surgeons. 

In  the  formation  of  these  German  military  medical  schools,  as  well  as 
the  similar  establishment  at  St.  Petersburgh,  the  first  idea  of  the  govern- 
ment seems  to  have  been  that  the  civil  schools  were  deficient  either  in 
number  or  capacity.  Moreover,  they  seem  to  have  thought  that  they  eould 
retain  physicians  after  they  had  got  them  educated. 

Neither  of  these  theories  was  correct,  for  the  foundation  of  the  difficulty 
lay  in  the  fact  that  the  position  of  the  army  surgeon  on  duty  with  a  regi- 
ment was  an  inferior  one,  and  distasteful  to  educated  gentlemen.  The 
army  officer  looked  down  with  quiet  contempt  and  condescension  on  men  who 
were  non-combatants,  and  knew  nothing  of  military  tactics,  and,  as  these 
positions  of  medical  officers  had  for  a  long  time  been  filled  by  men  of  the 
lowest  class,  it  had  been  found  possible  to  treat  them  as  servants  and  ap- 
pendages. Even  at  the  present  day,  so  persistent  are  traditions  and  cus- 
toms in  military  matters,  the  majority  of  men  trained  in  a  military  acad- 
emy, when  they  come  to  realize  the  sweets  of  command,  find  it  difficult  to 
realize  that  a  thoroughly  trained  physician  is  their  equal,  though,  in  fact, 
in  general  education,  he  is  often  their  superior. 

No  government  has  as  yet  fully  comprehended  the  fact  that  a  fully  edu- 
cated army  surgeon — such  a  one  as  it  would  be  satisfied  to  intrust  with 
the  care  of  its  troops  and  officers — can  only  be  obtained  and  retained  by 
giving  him  both  sufficient  pay  and  social  position  ;  and  it  will  probably  be 
a  long  time  yet  before  the  commonplace  axiom,  that  to  secure  a  regular 
supply  of  any  first-rate  article  you  must  at  least  give  the  market  price, 
will  be  accepted  as  applying  to  medical  officers  of  the  army  or  navy. 

Under  the  laws  relating  to  State  examinations  and  the  central  medical 
board,  as  no  one  could  practise  who  had  not  passed  the  State  examination, 
it  was  found  necessary  to  provide  for  the  wants  of  the  poorer  districts  by 
authorizing  an  inferior  grade  of  practitioners,  who  were  examined  mainly 

1  For  a  good  account  of  this  organization  consult  a  series  of  articles  by  Dr.  Bush- 
man, in  the  London  Medical  Times,  1849,  vols,  xix.,  xx. 


1878.] 


Higher  Medical  Education. 


179 


in  surgery  and  obstetrics,  and  who  corresponded  in  most  respects  to  the 
officier  de  sante  of  France.  Since  the  consolidation  of  the  empire  all 
this  has  been  changed.  At  the  present  time  any  one  can  practise  medi- 
cine in  Germany  without  a  diploma  and  without  an  examination,  and  the 
inferior  legal  class  of  practitioners  is  done  away  with.  But  no  one  may 
call  himself,  or  allow  himself  to  be  called,  physician  (Arzt)  unless  he  has 
passed  the  State  examination,  nor  doctor  unless  he  has  obtained  that  title 
by  the  University  examination,  and  these  two  titles  are  sharply  separated. 
The  doctor  is  not  a  physician  (Arzt)  unless  he  has  passed  the  State  board, 
and  the  Arzt  is  not  a  doctor  unless  he  has  passed  the  faculty  board.  The  man 
who  is  neither  Arzt  nor  doctor  practises  at  his  peril,  for  though  he  is  not 
forbidden  to  do  so,  yet,  if  any  mishap  occurs  from  his  ignorance,  he  is 
punished  not  only  by  tine,  but  by  imprisonment  for  a  period  varying  from 
six  months  to  ten  years. 

The  expenses  of  passing  the  State  board  are  less  than  half  those  for  the 
faculty,  and  the  examination  is  more  exclusively  practical ;  hence  it  is 
selected  by  the  poorer  students  who  seek  only  a  rural  practice. 

The  majority  of  students  pass  both  examinations,  and  this  is  especially 
necessary  for  those  who  aspire  to  any  medical  office. 

The  preliminary  examination  is  known  as  the  tentamen  physicum^  and 
the  same  preliminary  certificates  are  required  as  in  Austria.  It  includes 
anatomy,  physiology,  chemistry,  physics,  botany,  zoology,  and  mineralogy, 
and  is  usually  passed  at  the  end  of  the  second  year  of  university  life.  The 
State  examination  is  divided  into  four  parts,  corresponding  in  all  essential 
point*  to  the  Austrian  rigorosa.  In  the  examination  in  practical  medicine 
and  surgery,  the  candidate  has  to  treat  two  or  three  cases  in  each  branch 
for  about  a  week,  and  to  present  a  written  account  of  these  cases.  In  the 
Austrian  universities  a  thesis  for  graduation  is  no  longer  required,  but  it 
is  still  demanded  in  Germany,  though  not  always  printed. 

The  number  and  character  of  professorial  chairs  in  the  medical  facul- 
ties vary  greatly  in  the  different  universities,  but  in  all  we  find  three 
classes  of  teachers,  viz. :  professors,  extraordinary  or  assistant  professors, 
and  privat  docents. 

Thus,  at  Berlin,  there  are  14  professors,  14  assistants,  and  37  privat 
docents,  with  about  260  students ;  Kiel,  the  smallest  university,  with  55 
students,  has  7  professors  and  7  privat  docents;  while  Vienna,  the  largest, 
with  860  students,  has  19  professors,  38  assistants,  and  about  70  privat 
docents. 

The  professors  are  appointed  for  life,  and  at  the  end  of  thirty  years'  ser- 
vice can  retire  on  a  pension ;  they  receive  a  fixed  salary  from  the  State 
or  University — a  part  of  the  revenue  derived  by  the  medical  faculty  from 
certain  fees,  and  their  lecture  fees  from  the  students.  The  fixed  salary  is 
occasionally  increased  according  to  the  success  and  reputation  of  the  pro- 
fessor, and  the  total  salary  varies  from  2000  to  7500  dollars.  Any  doctor 
in  medicine  may  be  a  candidate  for  a  vacant  chair,  the  selection  being 
made  by  the  minister  of  public  instruction  from  a  list  of  names  recom- 
mended by  the  faculty. 

The  extraordinary  or  assistant  professors  are  appointed  in  like  manner 
from  among  the  privat  docents.  As  aTule,  their  compensation  comes  only 
from  students'  fees,  but  occasionally  a  small  fixed  salary  of  about  650  dol- 
lars is  allowed. 

The  position  of  privat  docent  is  accessible  to  all  doctors  of  medicine, 
and  the  number  is  unlimited.    Their  compensation  is  from  students'  fees, 


180 


Reviews. 


[July 


and  they  may  not  underbid  the  regular  professor.  At  some  universities 
they  are  furnished  with  rooms,  and  given  a  share  of  the  clinics  ;  at  others, 
they  receive  little  or  no  assistance. 

There  are  no  independent  medical  schools  in  Germany.  No  one  can 
open  a  course  on  his  own  responsibility,  and  the  universities  alone  have 
the  power  to  confer  academic  grades.  The  system  of  privat  docents,  how- 
ever, compensates  in  a  great  measure  for  this  want  of  freedom.  As  the 
test  of  fitness  for  a  degree  in  the  university,  or  for  the  position  of  practi- 
tioner in  the  State,  is,  mainly,  the  ability  to  pass  certain  examinations,  and 
as  the  salaries  of  the  professors  are  guaranteed  by  the  State,  it  is  evident 
that  it  makes  little  difference  as  to  precisely  when,  where,  or  how  the 
student  gets  his  information,  provided  only  that  he  really  gets  it. 

There  is,  therefore,  little  objection  to  free,  or.  as  it  is  sometimes  called, 
"  extra-mural  teaching/'  and  hence  young  men  of  ability  can  establish 
themselves  as  private  teachers,  demonstrators,  etc.,  in  the  immediate  vi- 
cinity of  the  universities,  relying  on  their  own  talents  and  tact  to  secure 
pupils.  These  are  the  privat  docents,  much  of  whose  teaching  consists 
in  giving  short  courses,  of  from  six  to  eight  weeks'  duration,  on  special 
subjects.  These  privat  docents  are  subject  to  certain  regulations,  and 
follow  in  a  general  way  the  teaching  and  directions  of  the  professor  of  the 
special  branch  to  which  they  attach  themselves;  they  are  understood  to  be 
in  training  for  professorships,  and,  if  they  show  marked  ability  as  teachers 
or  as  investigators,  their  promotion  may  be  very  rapid. 

When  a  professorship  becomes  vacant  in  a  German  university,  it  may 
occasion  several  changes,  especially  if  the  position  be  an  important  one, 
because  there  immediately  follows  an  effort  to  induce  the  best  man  from 
some  other  university  to  come  and  fill  the  vacant  place,  and,  if  this  be  suc- 
cessful, then  there  is  another  empty  chair  to  fill,  and  so  on.  Of  course, 
counter-inducements  are  held  out  by  the  universities  which  wish  to  retain 
their  famous  men,  and  thus  a  sort  of  auction  follows,  in  which  sometimes 
the  article  sold,  viz.,  the  professor,  can  almost  dictate  his  own  terms. 
When  we  use  the  wrords  "  auction"  and  "  sold,"  we  do  not  by  any  means 
intend  to  imply  that  it  is  purely  a  matter  of  money.  Social  position, 
orders  of  nobility,  handsome  residences,  or  special  facilities  for  scientific 
pursuits,  are  some  of  the  various  inducements  that  may  be  used. 

For  instance,  after  the  transfer  of  Strasburg  to  Germany,  neither  pains 
nor  money  was  spared  to  make  the  University  a  success.  For  the  chairs  of 
the  medical  faculty  rising  men  were  selected,  all  of  whom  were  known  for 
original  research  and  had  practically  proved  their  ability  as  teachers  and 
writers.  The  chair  of  pathological  anatomy  was  given  to  Recklinghausen, 
one  of  the  most  brilliant,  of  Yirchow's  pupils.  When  the  chair  of  patho- 
logical anatomy  at  Vienna  became  vacant  by  the  retirement  of  Rokitansky, 
it  was  offered  to  Recklinghausen,  and  the  salary  proposed  was  25,000 
francs,  or  about  three  times  the  usual  salary  of  such  a  professorship.  But 
the  Prussian  government  was  quite  as  anxious  to  retain  Professor  Reck- 
linghausen as  the  Austrian  government  was  to  obtain  him,  and  asked  him 
to  say  what  he  wanted.  His  reply  was  to  demand,  as  the  condition  on 
which  he  would  remain,  that  there  should  be  constructed  a  large  patho- 
logical institute,  in  accordance  with  his  plans,  and  in  connection  with  the 
hospital, — an  institute  which  will  cost  several  hundred  thousand  dollars, 
and  will  require  a  change  in  the  fortifications.  His  demand  was  acceded 
to,  and  he  is  hard  at  work  now  in  Strasburg. 

In  this  way  the  smaller  universities  become  training  schools  for  the 


1878.] 


Higher  Medical  Education. 


181 


professors  of  the  larger  and  wealthier  ones,  and  thus  the  most  powerful 
stimulus  possible  is  constantly  acting  on  all  teachers  throughout  the  two 
empires. 

For  instance,  the  medical  faculty  of  the  University  of  Kiel  is  in  an  out- 
of-the-way  place;  its  average  number  of  students  present  is  about.  50,  and 
it  has  a  clinic  of  about  200  patients  in  hospital.  Yet  in  this  small  estab- 
lishment began  to  teach  Stromeyer,  Langenbeck,  Frerichs,  Cohnheim,  and 
Esmarch.  The  latter,  in  fact,  is  still  there,  notwithstanding  offers  which 
have  been  made  to  him.  from  other  universities. 

Let  us  now  turn  to  the  manner  in  which  these  things  are  managed  in 
France. 

In  France  there  are  two  grades  of  physicians :  the  officier  de  sante,  or 
rural  practitioner,  and  the  doctor  of  medicine.  For  a  very  full  and  able 
discussion  of  the  merits  of  a  system  of  two  grades  of  practitioners  we  would 
refer  to  a  little  book  containing  the  debates  in  the  French  Legislative  As- 
sembly, in  the  spring  of  1847,  upon  the  subject  of  medical  organization 
in  France.1  At  that  time  the  first  general  medical  congress  of  French 
physicians  was  held  in  Paris,  and  a  new  journal,  the  Union  M  dicale, 
which  still  flourishes,  had  just  appeared  as  the  organ  of  French  medical 
opinion  as  expressed  in  the  congress.  The  main  points  in  dispute  were, 
first,  whether  there  should  be  more  than  one  grade  of  practitioners,  with 
corresponding  differences  in  the  methods  of  education  ;  second,  whether 
appointments  to  the  professional  chairs  should  be  by  concours. 

M.  Cousin  insisted,  in  opposition  to  the  opinion  of  the  majority  of  the 
physicians,  that  two  grades  of  medical  men  were  necessary,  the  officiers  de 
sante  for  the  requirements  of  the  people  in  thinly  settled  and  rural  dis- 
tricts, and  the  superior  grade  for  the  sake  of  medical  science.  He  also 
held  that,  while  the  concours  was  a  proper  means  of  selecting  the  ayreges, 
or  assistants,  it  was  not  the  best  way  of  obtaining  professors,  and  his  posi- 
tion in  both  these  questions  seems  to  us  to  have  been  correct. 

It  is  by  no  means  easy,  from  the  literature  of  the  subject,  to  appreciate 
the  existing  condition  of  medical  institutions  in  France,  or  to  learn  the 
causes  of  this  condition. 

As  her  schools  have  fallen  in  repute,  less  and  less  attention  has  been 
given  to  them  by  foreign  writers,  while  those  French  physicians  who  are 
really  well  acquainted  with  the  subject  are  disposed  to  be  reticent  from 
motives  of  pride  or  policy,  so  that  their  views  must  be  obtained  rather  by 
inference  from  the  points  which  they  specially  approve  in  other  countries, 
and  from  their  cautious  recommendations  for  legislation,  than  from  any 
direct  and  positive  statements. 

It  is  clear,  however,  that  the  hand  of  a  paternal  government  has  been 
lying  heavy  upon  medical  education,  and  that  centralization  has  been 
carried  to  an  extreme. 

The  organization  of  the  great  central  medical  faculty  at  Paris  and  its 
requirements  for  graduation  are  probably  well  known  to  all  our  readers, 
as  there  has  been  little  change  in  them  for  many  years.  Quite  recently, 
however,  a  number  of  reforms  and  improvements  have  been  projected, 
which  are  explained  in  the  article  of  Prof.  Chauffard.  The  most  impor- 
tant of  these  is  the  providing  of  new  buildings  for  the  faculty  and  for 
clinical  instruction,  for  which  purpose  the  sum  of  four  millions  of  francs 
has  been  granted,  one-half  coming  from  the  state,  the  rest  from  the  city. 

1  De  l'enseignement  et  de  l'exercise  de  la  medecine,  *  *  par  M.  Victor  Cousin. 
Paris,  1850.  i2mo. 


182 


Reviews, 


[July 


Heretofore  the  presentation  of  the  degree  of  bachelor  of  science  has  not 
been  required  until  the  middle  of  the  first  year  of  the  medical  student's 
course.  The  result  has  been  that  too  much  of  the  first  year  has  been  oc- 
cupied with  the  studies  pertaining  to  this  degree,  and,  as  the  four  years' 
course  required  is  too  short  already,  it  has  been  decided  that  the  degree 
of  bachelor  of  science,  as  well  as  of  arts,  shall  be  required  at  the  com- 
mencement of  the  medical  course. 

In  July,  1875,  a  law  relating  to  medical  education  was  passed  by  the 
National  Assembly  of  France,  in  which  it  is  declared  that  a  school  of 
medicine  may  be  established  in  any  city  which  will  pay  a  proper  share  of 
the  expenses. 

In  such  a  school  there  must  be  17  professors,  allotted  to  the  following 
chairs,  viz. :  Anatomy,  Physiology,  Internal  Pathology,  General  Pathology 
and  Pathological  Anatomy,  Hygiene  and  Legal  Medicine,  Operative  Sur- 
gery, Therapeutics,  Materia  Medica,  Botany  and  Zoology,  Medical  Chem- 
istry, Medical  Physics,  Pharmacy,  and  Clinical  Obstetrics,  each  one  ; 
Clinical  Medicine  and  Clinical  Surgery,  each  two. 

The  salary  of  each  of  these  professors  is  4000  francs,  with  1000  more 
for  the  director. 

There  must  be  eight  assistant  professors,  two  of  whom  are  assigned  to 
the  natural  sciences,  two  to  medicine,  two  to  surgery,  one  to  obstetrics, 
and  one  to  anatomy  and  physiology.  These  assistants  are  to  be  selected 
by  concours  and  appointed  for  ten  years  ;  their  salary  is  to  be  2000 
francs,  and  they  must  give  three  lectures  per  week.  The  law  then  goes 
into  the  details  of  assistants,  down  to  the  porters  and  messengers,  specify- 
ing their  duties  and  salaries. 

Everything  is  fixed  ;  it  is  not  supposed  that  the  faculty  which  is  to  do 
the  work,  or  the  municipality  which  is  to  bear  the  expense,  can  be  trusted 
to  decide  even  as  to  the  scrubbers,  or  how  much  they  should  be  paid. 

The  city  must  undertake  to  meet  all  the  expenses  for  salaries,  fuel, 
lights,  repairs,  and  books  and  material.  It  must  also  provide  two  amphi- 
theatres for  lectures,  an  office  for  the  director,  a  room  for  the  secretary, 
and  buildings  including  three  chemical  laboratories,  two  laboratories  for 
physics,  one  for  pharmacy,  one  for  physiology,  etc. 

The  faculty  must  have  at  its  disposal  in  a  hospital,  founded  by  itself  or 
furnished  to  it  by  the  government,  at  least  120  beds  habitually  occupied 
for  clinical  teaching;  there  must  be  two  clinical  amphitheatres,  and  each 
clinical  teacher  must  have  a  small  working-room  or  laboratory.  In  short, 
the  details  are  given  so  minutely  that  it  is  legitimate  to  infer  that  as  water- 
closets  are  not  mentioned  they  are  not  considered  desirable. 

The  pupils  of  the  free  faculty  may  be  examined  for  degrees  by  the  state 
faculty  on  proving  that  they  have  followed  the  prescribed  course,  or  they 
may  be  examined  by  a  special  board.  In  1876  it  was  enacted  that  all  ex- 
aminations must  be  undergone  in  the  state  faculties,  which  is,  of  course, 

a  very  serious  limitation  to  freedom  of  teaching  (Gaz.  Hebd.7  1876,  p. 

368.) 

It  is  fair  to  infer  that  this  legislation  was  intended  to  prevent  any  but  a 
large  and  wealthy  municipality  from  forming  a  medical  school,  and  to  give 
the  name  rather  than  the  substance  of  liberty  to  teach. 

Under  the  new  law  the  city  of  Lyons  made  a  formal  request  of  the  state 
for  the  creation  of  a  faculty  of  medicine  at  that  place,  promising  on  its 
part  to  put  up  buildings  which  should  cost  5,000,000  francs,  and  to  pay 
all  the  excess  of  expenditures  over  receipts  to  the  amount  of  300^000 


1878.] 


Higher  Medical  Education. 


183 


francs  per  year.  With  regard  to  the  organization  of  the  faculty,  a  sug- 
gestive and  valuable  report  was  made  to  the  municipal  council  by  Dr. 
Gailleton,  the  conclusions  of  which  were  adopted  and  recommended  to 
the  Minister  of  the  Interior.  After  urging  that  there  should  be  no  chairs 
of  the  accessory  or  natural  sciences  in  the  medical  faculty,  and  that 
chemistry,  physics,  and  natural  history  should  belong  to  the  faculty  of 
sciences,  he  says  : — 

"  We  would  suppress,  also,  the  chairs  in  which  the  professors  declaim  with 
more  or  less  eloquence  on  the  principles  of  medicine  and  surgery.  On  these  sub- 
jects a  good  book  is  of  more  use  to  the  subject  than  a  lecture.  This  teaching  is 
better  effected  by  conferences,  and  should  be  reserved  for  the  assistants  or  free 
professors.  The  clinics  should  be  increased,  and  should  include  diseases  of  the 
eye,  of  the  skin,  syphilis,  mental  diseases,  diseases  of  children,  diseases  of  the 
larynx,  diseases  of  the  ear,  and  of  the  urinary  organs." — {Lyon  Medical,  Nov. 
1876,  p.  333.) 

It  was  also  recommended  that  any  doctor  should  be  allowed  to  open  a 
course  or  to  teach  on  any  medical  subject,  and  the  student  should  have  the 
right  to  choose  his  professor.  The  uniformity  of  salary  for  the  professor 
is  objected  to.  This  salary  has  been  fixed  by  the  ministry  for  all  the  pro- 
fessors at  6800  francs  per  year. 

"We  consider  this  uniformity  of  salary  as  absolutely  incompatible  with  the 
prosperity  of  a  provincial  medical  school.  The  professors  must  be  divided  into 
two  classes  :  the  first,  devoted  to  pure  science  and  to  laboratory  researches, 
should  not  be  diverted  from  their  work  by  other  occupations ;  the  second,  by  the 
nature  of  their  teaching,  receive  money  from  practice.  The  professors  of  anatomy, 
of  physiology,  of  pathological  anatomy,  and  of  experimental  and  comparative 
medicine  ought  to  live  in  their  laboratories,  in  constant  contact  with  their  pupils. 
The  actual  direction  of  the  work  of  the  pupils  will  take  all  their  time." 

It  is  proposed,  therefore,  that  these  professors  shall  have  5000  francs 
extra  per  year.  It  is  also  strongly  insisted  on  that  in  each  laboratory 
there  must  be  an  assistant,  competent  and  well  paid,  and  that  these  are  as 
important  as  the  professors.1 

The  result  of  the  consultations  is  shown  by  the  decrees  of  April  22d 
and  24th,  1877.2 

The  composition  of  the  combined  faculty  of  medicine  and  pharmacy  of 
Lyons  is  as  follows  : — 

1st.  (25  chairs)  :  Anatomy,  1;  Physiology,  1;  General  Anatomy  and 
Histology,  1 ;  Pathological  Anatomy,  1  ;  Comparative  and  Experimental 
Medicine,  1  ;  Medical  and  Pharmaceutical  Chemistry,  1  ;  Medical  Phys- 
ics, 1  ;  Natural  History,  1  ;  Pharmacy,  1  ;  Internal  Pathology  (Medical), 
1  ;  External  Pathology  (Surgical),  1  ;  General  Pathology  and  Therapeu- 
tics, 1  ;  Hygiene,  1  ;  Therapeutics,  1  ;  Materia  Medica,  1  ;  Jurisprudence 
and  Toxicology,  1;  Operative  Surgery,  1;  Clinical  Medicine,  1;  Clinical 
Surgery,  1  ;  Clinical  Obstetrics,  1  ;  Clinical  Ophthalmology,  1  ;  Skin 
Diseases  and  Syphilis,  1  ;  Mental  Diseases,  1. 

2d.  Two  supplementary  clinical  courses  :  Diseases  of  Women,  1  ;  Dis- 
eases of  Children,  1. 

The  number  of  assistant  professors  (agreges)  is  to  be  22.  Three  of 
these  are  assigned  to  clinical  medicine,  one  to  jurisprudence,  one  to  thera- 
peutics, two  to  mental  disease,  six  to  clinical  surgery  and  obstetrics,  one 
to  anatomy,  one  to  pharmacy,  etc. 

1  See  Lyon  Medical,  19  Nov.  1876,  xxxiii.,  p.  410. 
3  Union  Med.,  April  28,  1877,  p.  705. 


184 


Reviews. 


[July 


One-half,  designated  by  lot,  serve  for  three  years,  the  other  half  for  six 
years.    The  appointments  are  to  be  by  concours. 

The  medical  faculty  of  Paris  consists  of  29  professors,  and  about  30 
agreges,  or  assistant  professors.  As  fixed  by  decree  of  Jan.  14th,  187(5, 
the  salary  of  a  professor  is  fixed  at  13,000  francs,  and  that  of  the  agrege 
at  4000  francs.  The  number  of  students  is  about  6000,  and  the  annual 
number  of  graduates  about  500.  The  Paris  school  has,  therefore,  a  larger 
number  of  medical  students  than  all  the  German  universities  together,  but 
its  students  are  nearly  all  French,  while  to  the  Austrian  and  German 
schools  they  come  from  all  parts  of  the  -world. 

The  systems  of  medical  education  and  of  medical  polity  in  all  the 
countries  of  Europe,  with  one  exception,  correspond  to  either  that  of 
France  or  that  of  Germany.  The  exception  is  Great  Britain,  and  the 
peculiarity  here  is  that  there  are  no  State  medical  schools.  The  schools 
are  private  corporations,  and  the  examining  and  degree-granting  powers 
are  also  private,  though  distinct  corporations. 

All  that  the  government  undertakes  is  to  publish  an  authentic  list  of 
qualified  practitioners,  and  to  define  the  minimum  of  qualification  which 
shall  entitle  a  physician  to  be  recorded  on  this  list. 

This  is  done  through  the  agency  of  a  body  known  as  the  General  Medi- 
cal Council,  which  may  be  considered  as  a  sort  of  medical  representative 
body  of  the  larger  medical  corporations.  The  reports  of  the  last  meeting 
of  this  council,  published  in  the  Lancet,  Medical  Times  and  Gazette,  and 
British  Medical  Journal  for  May  and  June,  1877,  will  be  found  to  give 
a  very  good  idea  of  the  existing  condition  of  medical  education  in  Great 
Britain  ;  and,  as  far  as  the  formation  of  practitioners  is  concerned,  the  re- 
sults may  be  said  to  be  fairly  satisfactory.  The  principal  complaint  made 
is  that  of  defective  preliminary  education  in  the  candidates,  and  that  the 
time  for  medical  studies  (four  years)  is  too  short.  The  professors'  fees  are 
derived  entirely  from  the  students. 

We  can  now,  perhaps,  appreciate  the  difference  between  the  French, 
German,  and  English  systems  of  medical  polity  and  of  medical  education, 
which  are  in  many  respects  well  marked.  In  France,  the  State  under- 
takes to  play  the  principal  part ;  the  schools  are  State  schools,  physicians 
are  State  officials.  Substantially,  thus  far,  the  effect  of  the  State  control 
has  been  to  centralize  instruction  in  the  Paris  school.  The  recent  law 
with  regard  to  the  formation  of  free  faculties  has  as  yet  had  little  effect ; 
and  in  fact  there  is  little  freedom  possible  so  long  as  the  State  on  the  one 
hand  fixes  the  courses  of  instruction  and  the  requirements  for  graduation, 
and  on  the  other  hand  bestows  such  pecuniary  aid  on  its  own  favoured 
institutions  that  it  is  almost  impossible  for  any  school  not  thus  assisted  to 
compete  successfully  with  them.  In  Germany  the  connection  between 
State  and  school  is  less  direct,  the  attitude  of  the  State  being  that  of  pro- 
tection and  encouragement  rather  than  of  immediate  direction ;  neverthe- 
less the  schools  are  essentially  State  institutions,  and  cannot  go  far  out  of 
a  certain  course  without  being  "  protected  and  encouraged"  back  into  it. 
The  marked  difference  between  France  and  Germany  is  the  number  of 
schools  all  nearly  on  an  equality,  and  the  healthy  competition  and  friendly 
rivalry  which  are  thus  Insured.  The  German  universities  are  great  corpo- 
rations, with  special  powers  of  jurisdiction  over  their  inmates,  and  it  is 
considered  a  special  honor  and  privilege  to  come  under  this  peculiar  juris- 
diction.   The  French  school  has  no  such  privileges. 


1878.] 


Higher  Medical  Education. 


185 


In  Great  Britain  the  State  has  but  little  to  do  with  the  matter.  The 
schools  themselves,  through  their  representatives  in  the  council,  regulate 
all  matters  of  education,  and  there  is  practically  no  law  against  irregular 
practitioners  or  quacks.  All  that  the  State  undertakes  is  to  see  that  the 
schools,  through  their  council,  shall  furnish  to  the  public  an  authoritative 
list  of  qualified  practitioners. 

In  a  few  of  the  older  universities  certain  professors  are  appointed  by  the 
Crown,  but  by  far  the  greater  number  are  selected  by  the  schools  them- 
selves. The  fees  of  the  professors  are  not  guaranteed  or  regulated  by  the 
State,  and  there  is  no  retiring  of  professors  on  a  pension. 

The  condition  of  medical  education  in  this  country  may  be  briefly 
summed  up  as  follows  : — 

There  arejnow  6")  medical  schools  in  the  United  States,  besides  those 
devoted  to  homoeopathy,  eclectic  and  botanic  systems,  etc.  During  the 
winter  of  187G-7,  these  G5  schools  had  7141  students,  of  whom  2313 
graduated  as  doctors  of  medicine  in  the  spring  of  1877.  There  were  em- 
ployed in  these  schools  515  professors,  and  279  other  teachers  with  various 
titles. 

In  five  of  these  schools  there  is  a  graded  course  of  three  years,  and  in 
two  a  preliminary  examination  is  required,  although  of  a  low  grade.  Of 
the  remaining  schools  about  15  are  doing  fairly  good  work,  work  as  good 
as  there  is  a  demand  for,  and  are  prepared  to  improve  as  rapidly  as  public 
opinion  and  financial  necessities  will  permit. 

The  rest  of  the  schools  are  doing  poor  work,  and  will  probably  continue 
to  do  it.  Many  of  them  owe  their  existence  to  the  desire  of  two  or  three 
gentlemen  to  advertise  themselves  without  coming  under  the  ban  of  the 
Code  of  Ethics.  What  an  individual  may  not  do  is  yet  permissible  to  a 
corporation.  The  profit  from  such  schools  does  not  come  from  the  fees  of 
the  students,  but  from  the  advertisement,  and  from  the  consultation  cases 
which  the  graduates  bring  to  the  professors.  They  can  well  afford,  there- 
fore, to  accept  lowr  tuition  fees,  or  even  to  teach  without  fees.  It  is  useless 
to  discuss  methods  of  improvement  for  this  class  of  schools  ;  the  only  use- 
ful reform  is  one  that  will  put  an  end  to  their  existence. 

The  amount  of  general  education  and  time  of  study  required  by  our 
medical  schools  are  about  the  same  as,  or  perhaps  a  little  less  than,  those 
required  for  veterinary  medicine  abroad. 

It  is  assumed  that  students  coming  up  for  their  first  course  have  been 
reading  with  a  private  preceptor  for  about  one  year. 

"  But  those  subjects  which  should  be  studied  first  are  precisely  those  which  re- 
quire demonstration  by  means  which  are  not  at  the  command  of  private  teachers, 
and  especially  of  those  in  the  rural  districts.  The  result  is  that  the  medical  stu- 
dent, instead  of  studying  chiefly  anatomy,  chemistry,  and  physiology,  does  his 
reading  on  these  subjects  in  a  mechanical,  listless  way,  and  gives  his  real  atten- 
tion to  works  on  practical  medicine  and  surgery,  because  he  has  some  cases  shown 
him  almost  every  day." 

This  "  American  system,"  as  it  is  called,  although  it  is  only  entitled  to 
this  name  because  it  has  been  retained  in  America  after  the  rest  of  the 
world  had  dropped  it,  is  really  one  of  the  great  causes  of  difficulty  in  the 
way  of  putting  our  systems  of  medical  education  on  a  satisfactory  footing. 
The  day  of  apprenticeships  and  private  pupilage  has  passed  for  all  stu- 
dents who  know  their  own  true  interests,  since  the  time  which  they  thus 
'spend  is  for  the  most  part  wasted,  being  taken  from  the  time  which  should 
be  given  to  laboratories,  hospitals,  and  lectures.    Many  members  of  the 


186 


Reviews. 


[July 


medical  profession,  however,  are,  and  will  be,  reluctant  to  give  up  this 
business  of  preceptorship.  "  It  a  Ids  a  little  to  their  income,  and  more 
to  their  importance;  it  makes  them  professors  in  a  small  way,  puts  some 
patronage  into  their  hands,  gives  them  an  office  boy  or  two,  and  need  be 
no  trouble  unless  they  choose,  and  in  most  cases  they  do  not  choose." 

All  attempts  to  compare  the  practical  skill  of,  or  the  results  obtained  by, 
the  physicians  of  the  United  States  with  those  of  other  countries  are  worse 
than  useless,  nor  in  fact  is  it  probable  that  the  methods  of  treatment  differ 
much,  for,  thanks  to  medical  journalism,  the  art  is  now  cosmopolitan,  and 
a  new  remedy  reported  from  England  or  Germany  will  very  speedily  be 
tried  here.  As  far  as  surgery,  and  especially  what  may  be  called  mechanical 
surgery,  is  concerned,  the  comparison  is  certainly  favourable  to  this  country. 
When,  however,  we  come  to  compare  our  medical  literature  with  that  of 
other  countries,  the  result  is  not  gratifying  to  our  national  pride  ;  and, 
after  all,  it  is  by  this  that  we  must  be  judged.  A  "  doctor"  should  be  a 
teacher  as  well  as  a  practitioner,  and  his  duties  do  not  end  with  the  cure 
or  death  of  his  patient.  He  ought,  for  the  sake  of  the  profession  and  the 
public,  to  set  forth  the  how  and  the  why  of  hi-  results. 

Defective  education  shows  its  effects  in  omissions  {is  well  as  commis- 
sions, and  in  this  respect  we  can  only  plead  guilty.  The  various  attempts 
which  our  physicians  have  made  to  produce  a  change  for  the  better  have 
not  as  yet  produced  any  striking  results,  but  the  attention  of  the  non- 
medical public,  which  is  after  all  the  party  most  immediately  interested, 
and  is  probably  the  only  source  from  which  effectual  reform  can  be  ex- 
pected, lias  been  to  some  extent  aroused,  so  that  it  is  probable  that  in  the 
course  of  time  our  legislators  will  provide  some  means  by  which  the  public 
can  distinguish  the  properly  trained  physician.  It  is  very  evident  that 
our  young  men  must  be  much  more  studious  and  intelligent  than  those  of 
France,  Germany,  Sweden,  or  Great  Britain,  or  else  that  they  must  he  less 
well  informed  on  graduation,  since  but  two  years  of  study  are  required  here 
for  that  purpose.  It  is  also  clear  that  the  course  of  reform  in  our  medical 
education  has  been  something  like  that  of  reform  in  the  civil  service. 
Every  one  agrees  that  it  is  a  most  desirable  thing,  but  the  majority  is  op- 
posed to  any  particular  mode  of  effecting  it. 

The  causes  of  the  dissatisfaction  which  exists  are  easily  understood  ; 
they  are  even  on  the  level  of  the  understanding  of  the  western  Bunsby, 
who  argued,  loud  and  long,  that  the  horse  could  never  trot  a  mile  in  two 
minutes,  "because  the  distance  was  too  great  for  the  time." 

The  defects  in  the  American  system  of  medical  education  are  summed 
up  by  Dr.  Pepper  as  follows  : — 

"1st,  the  absence  of  a  preliminary  examination  ;  2d,  the  very  short  term  of 
studies  required ;  3d,  the  want  of  personal  training  in  the  practical  branches  ; 
4th,  the  absence  of  any  grading  of  the  curriculum ;  5th,  the  examination  of  the 
candidates  for  the  degree  by  those  having  a  direct  pecuniary  interest  in  their 
success." 

The  evil  result  of  these  defects  upon  which  he  lays  most  stress  is  the 
over-production  of  medical  men.  He  estimates  that  in  the  United  States 
the  proportion  of  physicians  to  population  is  1  to  600,  while  in  Austria  it  is 
1  to  2500,  in  France  1  to  1814,  in  the  German  Empire  1  to  3000,  in  Great 
Britain  1  to  1672,  and  in  Sweden  1  to  7500.  These  estimates  are  based 
on  special  official  reports  obtained  through  the  State  Department,  and  the 
summary  of  these  reports,  given  in  an  appendix  to  the  address,  forms  a 
very  valuable  contribution  to  the  statistics  of  this  subject. 


1878.] 


Higher  Medical  Education. 


187 


Intimately  connected  with  the  excessive  production  of  improperly  edu- 
cated medical  men  is  the  prevalence  of  quackery  and  the  sale  of  fraudu- 
lent diplomas,  and  also  the  abuse  of  medical  charities  by  establishing  free 
dispensaries  to  furnish  clinical  material  for  the  medical  schools. 

It  will  be  found  interesting  to  compare  with  Dr.  Pepper's  address  the 
Carmichael  prize  essay  for  1873,  by  Dr.  Ashe.  The  Carmichael  prize 
essays  are  the  result  of  a  bequest  of  £3000  to  the  College  of  Surgeons  of 
Ireland,  the  interest  from  which  is  to  be  awarded  every  four  years  to  the 
best  essay  upon  the  state  of  the  medical  profession  in  Great  Britain  and 
Ireland,  on  the  state  of  the  hospitals  and  schools  of  medicine,  and  on  the 
state  and  mode  of  examination  or  testing  the  qualifications  of  candidates 
of  the  different  licensing  colleges  or  corporations  in  medicine,  surgery,  and 
pharmacy. 

Dr.  Ashe  finds  that  in  Ireland  there  are  at  least  24  per  cent,  more  phy- 
sicians than  are  needed,  and  that  to  this  supernumerary  24  per  cent.,  "  it 
is  due  that  the  public  can  treat  us  as  they  please,  can  pay  us  fees  or  not  as 
they  choose,  can  send  for  us  any  distance,  or  require  from  us  any  length 
of  attendance,  and  then  pay  us  at  their  own  tariff."  The  poor  law  medi- 
cal officers  attend  districts  varying  from  fifty  to  one  hundred  and  fifty  square 
miles  in  extent,  at  salaries  varying  from  7s.  to  2s.  9d.  per  day,  and  uso 
indiscriminate  is  the  character  of  the  poor  law  medical  relief  that  practice 
is  almost  abolished,  as  every  one  can  obtain  a  ticket  if  he  only  asks  for  it." 

"Yet,  when  one  of  these  appointments  falls  vacant,  what  happens?  A  rush 
is  made  from  all  quarters,  as  if  to  a  newly  discovered  Australian  gold  reef.  In 
the  hope  of  making  something  by  the  sale  of  medicines  in  an  unoccupied  district, 
men,  mostly  young  men,  nock  in  from  towns  like  those  we  have  spoken  of  above, 
where  there  are  two  or  three  doetors  per  1000  inhabitants.  Active  canvassing 
goes  on,  for  is  not  4s.  6d.  a  day  with  a  shop  better  than  the  shop  without  the  4s. 
6c/.,  even  though  severe  labour  has  to  be  incurred,  and  the  expense  of  a  horse  and 
man  has  to  come  out  of  the  4s.  6d.  ?  Of  course  the  committee  conclude,  that,  as 
there  are  so  many  applicants,  they  have  offered  ample  remuneration.  If  an  in- 
crease of  salary  is  afterwards  asked  for  by  the  successful  candidate,  they  oppose 
it,  on  the  grounds  that  they  ean  get  plenty  of  eager  applicants  at  the  same  salary, 
so  the  doetor  can  go  if  he  is  dissatisfied." 

The  remedy  proposed  by  Dr.  Ashe  is  to  increase  the  severity  of  the 
preliminary  examinations,  so  that  about  one-third  of  those  now  passing 
shall  be  excluded.  He  frankly  avows  that  this  limiting  of  numbers  is 
trades-unionism,  pure  and  simple,  but  contends  that  it  is  trades-unionism 
only  in  its  legitimate  feature,  in  order  to  place  physicians  before  the  public 
in  the  position  of  parties  to  a  contract  for  their  services,  instead  of  suppli- 
ants for  employment  at  any  time. 

Let  us  turn  now  to  the  remedies  proposed  for  the  condition  of  things  in 
the  United  States.  As  far  as  protection  to  the  public  from  incompetent 
practitioners  is  concerned,  the  majority  of  the  medical  profession  are  pro- 
bably of  the  opinion  that  the  government  should  interfere  in  some  way,  but 
in  what  way  is  by  no  means  generally  agreed  upon.  It  is  clear  that  it  is  a 
matter  that  is  under  the  jurisdiction  of  the  several  States,  and  that  Con- 
gress can  do  nothing  directly.  All  that  the  General  Government  can  do  is 
to  encourage  a  high  standard  of  education  in  its  medical  officials,  and  to 
provide  facilities  for  medical  teachers  and  writers  in  the  shape  of  a  national 
medical  library  and  museum.  It  wrould  also  be  possible  for  it  to  publish 
an  official  medical  register,  in  which  the  degrees  obtained  by  each  physi- 
cian should  be  noted ;  but  this  would  be  of  little  use,  because  the  degrees 
under  existing  circumstances  are  of  little  value. 


188 


Reviews. 


Dr.  Pepper  thinks  that  eacli  State  should  prescribe  the  number  of  years 
to  be  devoted  to  medical  studies  before  graduation,  and  should  create  a  State 
board  of  examiners,  who  alone  should  have  the  right  to  confer  licensee  to 
practise  within  the  limits  of  the  State.  Tliis  would  probably  be  an  effect- 
ual remedy,  provided  that  public  sentiment  would  permit  the  infliction 
of  penalties  upon  those  who  practised  in  violation  of  the  law.  Such  a 
public  sentiment  does  not  exist  at  the  present  time,  and  we  do  not  believe 
that  it  will  exist  for  a  long  time  to  come.  Compulsory  and  official  registra- 
tion of  practitioners  seems  much  more  practicable,  and  we  should  be  glad  to 
see  this  experiment  fairly  tried.  As  a  commencement,  and  for  the  pur- 
pose of  obtaining  information,  we  should  be  glad  if  the  next  census  could 
register  them  all,  good  and  bad,  somewhat  after  the  plan  proposed  by  De 
Morgan. 

"  Let  the  Register  give  the  name,  address,  and  asserted  qualification  of  each. 
.  .  .  .  Let  it  be  competent  to  any  man  to  describe  himself  as  qualified  by 
study  without  a  diploma,  ....  or  even  by  intuition  or  divine  inspiration  if  he 
please.  Let  all  qualification  which  of  its  own  nature  admits  of  proof  be  proved, 
as  by  the  diploma  or  certificate,  etc.,  leaving  things  which  cannot  be  proved,  as 
asserted  private  study,  intuition,  inspiration,  etc.,  to  work  their  own  way. 

"Let  it  be  highly  penal  to  assert  to  the  patient  any  qualification  which  is  not 
in  the  Register."  (De  Morgan,  A.  A.,  Budget  of  Paradoxes,  London,  1872, 
8vo.,  p.  1G0.) 

In  addition  to  this,  De  Morgan  proposed  to  make  it  a  penal  offence  to 
practise  if  unregistered. 

His  suggestion  was  given  half  in  jest  and  half  in  earnest,  and  it  is  plain 
that  the  value  of  an  annual  official  Register  of  Physicians,  such  a-  is 
now  issued  in  Great  Britain,  would  be  destroyed  to  a  great  extent  were 
every  claimant  included  ;  but  for  statistical  purposes,  and  to  give  some 
positive  data  for  legislative  action,  it  seems  worthy  of  consideration. 

In  view  of  the  defects  complained  of,  how  does  it  happen  that  the  great 
majority  of  our  practitioners  are  fairly  skilled  in  their  art,  and  that  the 
results  of  their  treatment  will  compare  favourably  with  those  of  foreign 
physicians  ?  We  suppose  it  is  because  the  majority  of  them  gain  the 
most  valuable  part  of  their  skill  at  the  expense  of  their  first  patients. 
How  else  can  they  get  it,  at  least  as  regards  internal  therapeutics  ?  As 
far  as  mechanical  surgery  and  those  specialties  which  depend  mainly  on 
mechanical  appliances  are  concerned,  it  is  easy  to  see  why  preliminary 
education  and  general  culture  are  of  minor  importance.  It  should  also  be 
remembered  that  a  very  considerable  proportion  of  the  medical  profession 
in  this  country  have  not  limited  the  time  of  their  studies  to  the  usual  two 
years'  curriculum.  Many  of  them  have  studied  three  years,  a  goodly 
number  have  added  a  fourth  year  in  hospital  service,  and  over  one  per 
cent,  have  studied  in  foreign  schools.  If  a  man  wants  a  really  skilful 
practitioner  there  are  few  localities  in  the  United  States  where  he  cannot 
be  found  or  brought  without  much  trouble.  Let  it  not  be  supposed  that  we 
consider  the  condition  of  things  satisfactory.  Far  from  it,  but  we  are 
just  now  considering  the  question  of  the  supply  of  practitioners  for  the  peo- 
ple, and  it  seems  to  be  not  so  bad  after  all,  being  nearly  as  good  as  there 
is  a  demand  for,  which,  according  to  political  economists,  is  the  main 
point,  and  it  is  from  this  point  of  view  that  the  public  and  its  representa- 
tives, the  legislators,  must  view  it. 

From  the  point  of  view  of  the  well-educated  physician  the  case  is  dif- 
ferent. Small  wonder  that  he  should  feel  discontented  when  he  sees  the 
sort  of  men  with  whom  he  is  classed  by  the  public.    His  only  hope  for  im- 


1878.] 


Higher  Medical  Education. 


189 


provement,  however,  must  be  in  the  education  of  this  public.  As  far  as 
the  better  class  of  schools  are  concerned,  it  is  difficult  for  them  to  eifect 
improvement,  but  it  is  by  no  means  impossible.  The  experience  of  Har- 
vard and  of  the  University  of  Pennsylvania  shows  that  extending  the 
course  of  study  to  three  years  will  be  a  financial  success.  Far  more  im- 
portant, however,  than  lengthening  the  curriculum,  is  the  establishing  a 
satisfactory  preliminary  examination.  It  is  at  the  very  beginning  that 
incompetent  men  should  be  rejected,  and  this  for  their  own  sake. 

No  such  examination  has  yet  been  tried  in  this  country,  nor  can  it 
probably  be  maintained  by  an  institution  which  is  not  so  endowed  as  to  be 
comparatively  independent  of  the  students'  fees.  These  fees  in  fact  are 
but  a  small  proportion  of  the  cost  of  properly  educating  a  medical  man, 
which  is  about  two  thousand  dollars.  Billroth  estimates  the  cost  to  a 
university  of  a  course  of  five  years,  such  as  he  recommends,  as  being  about 
$2500  for  eacli  student,  and  his  chapter  on  this  subject  will  be  found  espe- 
cially interesting. 

Thus  far  we  have  been  considering  the  subject  of  medical  education 
from  the  point  of  view  from  which  the  majority  of  authors  and  essayists 
view  it.  namely,  as  designed  to  produce  medical  practitioners, — as  fitting 
men  for  the  art  or  handicraft  of  medicine.  This  is  the  article  for  which 
the  demand  is  evident,  and  the  supply  corresponds.  We  have  plenty  of 
officiers  de  sante  in  this  country,  too  many,  in  fact ;  but  it  is  not  so  clear 
that  we  have  too  many  doctors,  using  that  title  in  its  proper  sense. 

What  is  the  prospect  in  this  country  for  the  production  of  men  qualified 
to  teach  medicine  and  the  cognate  sciences,  and  to  carry  on  original  re- 
search ?  We  think  it  probable  that  this  also  we  may  hope  to  see  accom- 
plished. A  new  university  is  just  now  taking  shape  in  Baltimore  which 
has,  to  a  great  extent,  the  means  to  undertake  this  special  work,  and  the 
authorities  of  which  are  now  considering  this  problem  of  medical  educa- 
tion with  reference  to  the  mode  in  which  they  should  organize  their  medi- 
cal department.  Let  us  hope  that  their  decision  will  be  a  wise  one,  and 
that  a  sufficient  number  of  young  men  may  be  found  in  this  country  to 
appreciate  the  opportunity  which  will  thus  be  afforded  them. 

At  the  present  time  the  duty  of  those  physicians  who  wish  to  see  our 
present  system  of  medical  education  improved  is  plain.  They  should  ex- 
ert their  influence  in  favour  of  those  schools  which  have  adopted  the  three 
years'  course,  which  have  good  laboratory  and  clinical  facilities,  and  which 
exact  the  greatest  amount  of  preliminary  education  in  their  students. 
They  should  advise  their  young  friends  and  pupils  to  go  to  these  schools, 
and  to  avoid  others,  and  show  them  that  it  is  to  their  OAvn  interest  to  do 
this. 

As  to  legislative  restrictions  on  the  practice  of  medicine,  we  doubt  the 
policy  of  urging  them  by  members  of  the  profession.  Any  law  which 
accepts  a  diploma  as  evidence  of  competency  is  especially  objectionable, 
for  it  offers  a  premium  to  schools  of  a  low  grade.  This  objection  applies 
also  to  registration  laws,  but  in  a  less  degree.  The  special  value  of  regis- 
tration is  that  it  will  furnish  some  positive  data,  and  thus  enable  those 
who  are  really  and  practically  interested  in  the  subject  to  see  precisely 
what  is  the  extent  of  the  evil  which  they  propose  to  combat. 

J.  S.  B. 


190 


Reviews. 


[July 


Art.  XIX — T?ie  Retinal  Red  and  its  Relation  to  the  Sensation  of  Sight. 
Zur  Anatomie  und  Physiologie  der  Retina.    Von  F.  Boll.  Berliner 

Acad.  Monatsberichten,  1876.    S.  A.  5  Stn. 
Zur  Photochemie  der  Netzhaut.    Von  W.  Kuhne.    XJber  den  Sehpur- 

pur.    Von  W.  Kiihne.     Erganzungslieft  zu  den  Verhandlungen  des 

Naturhistorisch-medicinischen  Vereins  zu  Heidelberg.    B.  1,  H.  1, 

1877. 

Zur  Physiologie  des  Sehens  und  der  Farbenempfindung.  Von  F.  Boll. 

Berl.  Akad.  Monatsber.,  11  Jan.  1877,  7  Stn. 
Nachtrdgliche  Zus'dtze  zu  dieser  Mittheilung.    Ebendas,  15  Feb.  3 
Stn. 

Der  Sehpurpur  beobachtet  im  Auge  eines  gehenkten  Menschen.  Von 
Prof.  Schenk  und  Dr.  ZuCKERKANDL.  Allgemeine  Wien.  Z<  it- 
schrift,  N.  11,  1877. 

Zur  Farbe  der  Netzhant.  Von  E.  Fuchs.  Wien.  Med.  Woch.  N. 
11,  1877. 

Ueber  die  Verbreitung  des  Sehpurpurs  im  Menschlichen  Auge.  Von 

W.  Kuhne.      Weitere  Beobachtungen   iiber   den  Sehpurpur  des 

Menschen.    Von  W.  Kuhne.    Das  Sehen  ohne  Sehpurpur.    A  on 

W.  Kuhne.    Untersuchungen  iiber  den  Sehpurpur.   Von  A.  Ewai.d 

und  W.  Kuhne.    Erg&nzungsheft  z.  d.  Verhand.  des  Nat.-EQst.-Med. 

Vereins  zu  Heidelberg,  B.  1,  H.  2,  1877. 
Ophthalmoscopische  Mittheilung  en  iiber  den  Purpur  der  Retina.  Von 

Dr.  Helfreich.    Centralblatt  f.  Medic.  Wissen.  X.  7.  1«77. 
Untersuchungen  iiber  die  Wahrnehmbarkeit  des  Sehpurpurs  mit  dem 

Ophthalmoskope.    Von  Dr.  M.  J.  Dietl  und  Dr.  Ferd.  Plenk. 

Centralblatt  fiir  die  Med.  Wissen.,  1G,  1877. 
Ueber  die  Diagnose  des  Sehpurpurs  im  Leben.     Von  Dr.  E.  A. 

Coccius.    Leipzig,  3  Juni,  1877. 
Ueber  die  Darstellung  von  Optogrammen  im  Froschauge.    Von  W. 

Kuhne.     Untersuchungen  iiber  den  Sehpurpur.    Von  A.  Ewald 

und  W.  Kuhne.    Erganzungsh.  z.  d.  Verhand.  des  Natur hist. -Med. 

Vereins  zu  Heidelberg,  B.  1,  H.  3,  1877. 
Zur  Anatomie  und  Physiologie  der  Retina.    Von  F.  Boll.    Arch.  f. 

Anat.  u.  Physiol.    Physiolog.  Abth.,  1877.    S.  4-36. 
Zur  Lehre  vom  Lichtsinne.    Von  E.  He  king.    AVierer  Sitzungsbe- 

richte,  v.  66,  68,  69,  1872-1874. 
Die  Macula  lutea,  anatomisch  und  ophthalmoscopisch.    Von  Herm. 
^  Schmidt-Bimpler.    Arch.  f.  Ophthal.,  xxi.  3,  p.  17,  1876. 
Etudes  chimico-physiologiques  sur  les  matieres  colorantes  de  la  refine. 

Par  Stefano  Capranica.    Annales  d'Oculistique,  T.  lxxviii,  p. 

144,  1877. 

The  theory  of  vision,  proposed  by  Dr.  Young  about  the  beginning  of 
the  century  and  afterwards  revived  by  Helmholtz,  after  holding  undisputed 
sway  for  a  number  of  years,  seems  at  last  about  to  be  dethroned.  The 
first  effective  attack  was  made  upon  it  by  Prof.  F.  Boll,  of  the  Royal  Uni- 
versity of  Rome,  when  he  announced  that,  the  retina  contained  a  red  colour 
that  quickly  disappeared  on  exposure  to  light.  The  retinal  red,  according 
to  Boll,  is  best  demonstrated  in  tlie  eye  of  a  frog  (Rana  temporaria) 
which  has  been  kept  in  a  dark  place  for  several  hours.  The  eye  is  then  enu- 
cleated by  the  aid  of  a  feeble  artificial  light,  cut  in  half,  the  retina  taken 


]  878.]    Retinal  Red  and  its  Relation  to  the  Sensation  of  Sight. 


191 


out  and  laid  upon  its  inner  side  upon  a  white  surface.  If  now  examined 
by  a  good  light,  the  purplish-red  colour  of  the  membrane  is  very  evident. 
In  10  to  20  seconds,  however,  the  rosy  tint  vanishes,  to  be  replaced  by  a 
yellowish,  satiny  lustre,  which  lasts  from  30  to  60  seconds.  Gradually 
this  also  disappears,  and  the  retina  becomes  transparent  and  colourless.  In 
this  condition  it  remains  for  perhaps  a  quarter  of  an  hour,  but  at  last  is 
found  to  be  white  and  opaque.  Microscopical  examination  shows  that  the 
red  colour,  as  well  as  the  yellowish  tint  of  the  second  stage,  is  exclusively 
confined  to  the  outer  segments  of  the  rods.  The  white,  opaque  appearance  of 
the  last  stage  is  owino-  to  the  coagulation  of  the  albuminous  matters  in  the 
other  layers  of  the  retina.  These  peculiarities  of  the  membrane  may  be 
found  in  nearly  all  animals  which  possess  a  retina  with  rod  and  cone 
layer,  but  last  longer  and  are  more  easily  observed  in  the  amphibia  and 
cartilaginous  fishes,  which  have  retina  with  large  rods,  than  in  the  mam- 
malia and  bony  fishes,  which  mostly  have  fine  rods  and  cones.  In  the 
mammalia  the  colour-changes  take  place  so  rapidly  under  the  influence  of 
light  that  it  is  difficult  to  observe  them.  In  crabs  and  cephalopods,  on  the 
other  hand,  the  colour  is  especially  well  marked  and  enduring.  In  the 
frog,  however,  the  microscope  shows  that  all  the  rods  are  not  red.  A 
small  proportion  of  them  are  of  a  bluish-green  colour. 

Dr.  W.  F.  Xorris  and  the  writer  have  together  repeated  some  of  Boll's 
experiments  and  those  of  other  investigators,  as  will  hereafter  be  men- 
tioned, and  have  always  been  successful  in  obtaining  the  above-described 
results  with  the  frog's  retina.  In  the  microscopical  examinations  we  found 
that  the  green  rods  were  in  a  varying  proportion  of  from  1  to  5  or  10  of 
the  purplish  ones,  and  that  after  the  latter  had  become  quite  colourless,  the 
former  were  still  visible,  but  lighter  and  more  bluish  in  colour.  Indeed, 
the  green  rods  apparently  increased  in  numbers  as  the  red  ones  faded. 

Schenk  and  Zuckerkandl  have  also  observed  the  retinal  red  in  eyes  re- 
moved from  criminals  after  execution,  and  E.  Fuchs  has  ascertained  its  ex- 
istence in  the  eyes  of  still-born  babes.  The  retinal  colour  lias  been  studied, 
with  persistent  industry  and  a  vast  consumption  of  material,  by  Kiihne,  of 
Heidelberg.  He  has  published  a  series  of  papers  on  the  vision  purple,  and 
was  probably  the  first  to  take  a  successful  optogram.  He  recommends  that 
the  experiment  should  be  tried  on  an  atropinized  and  curarized  rabbit,  whose 
refraction  has  been  previously  determined  by  the  ophthalmoscope.  The  sub- 
ject of  the  picture  usually  taken  was  a  window,  with  narrow  pieces  of  board 
tacked  to  the  frame  and  cross-bars  so  as  to  exclude  much  of  the  light  and 
make  an  easily  recognizable  object.  The  animal  was  placed  in  the  room 
in  front  of,  and  somewhat  below,  this  window,  at  a  distance  of  1.75  m. 
After  10  minutes'  exposure,  the  rabbit  was  killed  and  the  eye  extirpated 
in  a  dark  room,  by  the  aid  of  a  sodium  flame.  The  bulb  was  opened  and 
placed  in  a  5  per  cent,  solution  of  alum,  in  order  to  make  the  retina  tough 
enough  to  allow  of  its  removal.  After  remaining  in  the  alum  solution  for 
twenty-four  hours,  the  eye  was  halved,  the  optic  nerve  entrance  cut  out 
with  a  punch,  the  retina  detached  underwater  and  floated  on  to  a  porcelain 
scale,  so  that  its  outer  surface  should  be  upwards.  Examined  by  daylight 
the  picture  was  barely  visible.  Two  minutes  after  the  death  of  the  animal 
the  other  eye  wras  placed  in  position  for  receiving  the  image  of  the  wTindow, 
and  treated  as  before.  The  picture  obtained  in  this  eye  was  very  good. 
Several  repetitions  which  we  made  of  this  experiment  were  uniformly 
unsuccessful.  We  always  found  the  retinal  red  of  the  rabbit  so  faint  as 
scarcely  to  admit  of  a  bleached  spot  being  seen.    Indeed,  Kiihne  says 


192 


Reviews. 


[July 


that  any  light  strong  enough  to  see  the  optogram  by,  is  strong  enough  to 
bleach  it,  and  subsequently  recommends  that  the  retina  should  be  dried  in 
an  exsiccator,  over  sulphuric  acid,  for  twenty-four  hours  before  examina- 
tion. In  this  way  the  colour  is  fixed  for  a  time.  We  found  this  to  be  the 
case  with  frog's  retinas. 

Kiihne  claims  to  have  obtained  excellent  optograms  by  using  the  eyes 
of  oxen,  even  an  hour  after  death.  In  the  living  frog,  also,  he  got  a  good 
picture  of  a  gas-flame,  in  front  of  which  the  animal  had  been  induced  to 
sit  quietly  for  two  hours.  In  all  these  cases  no  picture  can  be  seen  on  the 
front  of  the  retina,  if  it  be  examined  at  once  and  in  situ,  but  only  after 
removal  from  the  eye  is  the  picture  visible  in  the  back  of  the  membrane. 
His  remark  that  it  is  useless  to  attempt  to  take  optograms  unless  one  has 
plenty  of  time  to  devote  to  the  subject,  is,  according  to  our  experience, 
perfectly  accurate. 

Boll  soon  after  published  a  paper  in  which  he  gave  a  resume  of  the 
facts  connected  with  his  discovery,  and  mentioned  that  he  had  placed  a 
curarized  frog  in  such  a  position,  behind  the  almost  closed  shutter  of  his 
window,  that  the  thinnest  possible  ray  of  sunshine  admitted  between  them 
should  fall  upon  the  animal's  eyes.  After  ten  minutes'  exposure  the  eye 
was  removed,  and  the  retina  found  to  be  divided  into  two  lateral  red-coloured 
halves  by  a  vertical  white  line. 

Kiihne,  however,  is  of  the  opinion  that  an  optogram  is  not  so  readily 
taken  as  this  result  would  seem  to  indicate.  He  repeated  the  experiment, 
and  ascertained  that  on  account  of  the  sun's  apparent  motion  "  the  thinnest 
possible  ray  of  sunshine"  would  not  remain  on  the  frog's  eye  for  ten 
minutes.  This  difficulty,  however,  he  met  by  the  use  of  a  heliostat.  He 
then  found  that  an  exposure  of  twenty  minutes  instead  of  ten  was  neces- 
sary to  produce  a  perceptible  line,  but  even  then  it  was  not  well  defined. 
From  our  own  experiments  we  should  be  disposed  to  consider  the  line 
described  by  Boll  as  probably  accidental.  Such  streaks  occasionally  occur 
without  obvious  reason  in  retinas  which  have  been  exposed  to  strong  light. 
Perhaps  it  may  have  been  caused  by  the  absolutely  necessary  use  of  the 
forceps  in  the  removal  of  the  membrane  from  the  bulb.  From  a  variety 
of  experiments  Kiihne  deduced  the  conclusion  that  the  distance  of  distinct 
vision  in  the  frog's  eye  was  from  12  to  50  centimetres.  The  best  dis- 
tance is  probably  about  15  centimetres.  He  also  found  that  if  the 
retina  is  bleached  quickly,  in  a  bright  light,  the  pigment  cells  adhere 
to  it  and  obscure  the  picture.  This  is  quite  in  accordance  witli  our 
own  experience.  He  therefore  adopted  as  a  test  object  a  pane  of  ground 
glass,  45x55  centimetres,  on  which  were  pasted  five  strips  of  black 
paper,  each  5  centimetres  wide,  so  that  the  entire  pane  was  divided  into 
alternate  translucent  and  opaque  stripes.  The  curarized  frog  was  placed 
on  a  cushion  of  soft  black  wool,  its  eyes  made  prominent  by  means  of  a 
paper  ball  in  its  mouth,  and  at  the  distance  of  15  centimetres  subjected  to 
the  mild  light  coming  through  this  pane  for  an  hour  or  more.  The  picture 
taken  in  this  way  covered  half  the  retina.  We  repeated  this  experiment 
on  a  dozen  different  eyes,  and  in  three  cases  only  with  satisfactory  results. 
We  found  that  the  best  subjects  for  the  trial  were  very  large  specimens  of 
the  Rana  pipiens,  one  of  those  we  used  measuring  over  thirteen  inches 
in  length.  In  a  single  instance  only  were  the  stripes  visible  on  the  retina 
in  red  and  white.  In.  the  other  two  cases  lines  of  adherent  pigment 
marked  the  places  where  the  bands  of  light  from  the  window-pane  had 
been  focused,  so  that  the  image  appeared  reversed,  in  white  and  black. 


1878.]    Retinal  Red  and  its  Relation  to  the  Sensation  of  Sight. 


193 


It  is  probable,  however,  that  this  proportion  of  successful  results  may  be 
considered  satisfactory,  for  the  causes  of  failure,  such  as  too  long  or  too 
short  exposure,  variations  in  light  intensity,  the  difficulty  of  removing  the 
retina  entire  and  without  distortion,  and  the  troubles  attendant  upon  the 
manipulation  of  so  small  an  object  as  a  frog's  eye,  are  so  numerous  that 
even  Kiibne  admits  that  he  sometimes  failed.  Our  best  picture  was  taken 
after  an  exposure  of  only  45  minutes,  with  the  sun  shining  on  the  pane. 
When  the  glass  transmitted  the  light  from  a  blue  sky  only,  two  hours  were 
required  to  produce  the  optogram. 

In  another  paper  (Zer  Photochemie  der  Netzhaut)  Kuhne  discusses  the 
effect  of  other  agents  than  light  upon  the  retinal  colour.  The  tint  is  destroyed 
by  a  temperature  of  100°  C.,  by  alcohol,  acetic  acid  and  by  a  10  per  cent, 
solution  of  soda.  It  is  not  affected  by  a  per  cent,  solution  of  common 
salt,  strong  ammonia  water,  2  per  cent,  solution  of  acetic  acid,  alum,  gly- 
cerine, ether  and  drying.  The  rays  of  light  at  the  spectroscopic  line  D 
have  almost  no  effect  on  the  colour,  and  in  this  connection  it  is  remarkable 
that  only  the  most  deeply  tinted  retinas,  for  example  those  from  the  Rana 
temporaria,  exhibit  to  the  observer  a  perceptible  tinge  of  red  when  viewed 
by  the  sodium  light.  The  colouring  substance  is  separable  from  the  retina 
by  solution.  Kuhne  puts  about  twenty  retinas,  freshly  taken  from  frogs' 
eyes,  into  from  half  a  gramme  to  one  gramme  of  a  5  per  cent,  watery  solu- 
tion of  crystallized  and  colourless  ox-gall,  in  a  small  test  tube,  lets  them 
stand  for  forty-eight  hours,  and  filters.  The  resulting  solution  is  perfectly 
clear,  and  of  a  splendid  carmine-red  colour.  Exposed  to  light  it  becomes 
first  orange,  then  yellow,  at  last  colourless  as  water.  In  direct  sunshine 
the  bleaching  is  instantaneous.  In  diffused  daylight  the  fading  varies  in 
rapidity  according  to  the  light  intensity.  The  colour  is  perceptibly  slower 
in  disappearing  in  the  afternoon  than  in  the  morning,  or  at  mid-day.  In 
this  respect  it  is  like  other  photochemical  agents.  The  colouring  sub- 
stance probably  exists  in  the  retina  in  solution,  for  if  a  fresh  retina  is  made 
to  adhere  to  a  glass  slide,  and  this  is  exposed  to  light  in  a  vertical  position, 
the  lower  edge  of  the  membrane  always  bleaches  last ;  and  if  a  row  of 
retinas  are  thus  placed,  touching  one  another,  the  lowest  retains  its  hue 
many  minutes  longer  than  the  highest. 

According  to  Boll  the  colour  of  a  retina,  which  has  been  for  some  time 
in  obscurity,  is  red,  corresponding  to  the  middle  of  the  spectrum  red.  He 
suggests  the  name  JErytkropsine  for  the  colouring  matter.  A.  Ewald  and 
W.  Kuhne  made  a  large  number  of  experiments  (  Untersuchungen  iibe?* 
den  Sehpurpur)  to  determine  the  precise  shade  of  the  retinal  tint.  They 
endeavoured,  by  means  of  the  well-known  method  of  Helmholtz,  to  find 
the  hue  which  would  combine  with  that  of  the  retina  to  make  white,  and 
finally  concluded  that  the  complementary  colour  is  pure  green,  that  part  . of 
the  solar  spectrum  between  E  and  b.  Analysis  of  the  colour  by  means 
of  the  spectroscope  was  found  to  be  unsatisfactory  on  account  of  the  rapid 
change  of  tint  under  the  action  of  light.  They  conclude,  however,  that 
the  colour  is  purple,  and  name  the  colour-giving  material  Rhodopsin. 

Under  the  influence  of  the  ultra  violet  rays  of  the  solar  spectrum  the 
retina  becomes  fluorescent.  The  purple  rods  appear  blue.  If  bleached 
they  look  green,  and  still  more  fluorescent.  The  anterior  layers  of  the 
retina  become  faintly  bluish.  An  optogram  examined  by  these  rays  shows 
a  green  picture  on  a  blue  background.  Ewald  and  Kuhne  suggest  the  pos- 
sibility of  seeing  an  optogram  in  situ  in  the  living  human  aphakial  eye  by 
means  of  the  ophthalmoscope,  using  the  ultra  violet  rays.  When  it  is 
No.  CLI  July  1878.  13 


194 


Re  vie  \vs. 


[July 


remembered,  however,  that  their  illuminating  power  is  so  slight  that  they 
cannot  be  seen  when  focussed  on  white  paper,  it  must  be  confessed  that 
such  an  examination  would  be  accompanied  with  some  difficulty.  The 
ophthalmoscope,  indeed,  has  not  yet  made  the  retinal  red  quite  clear  in 
the  living  eye.  Helfreich,  it  is  true,  claims  to  have  seen  the  retina  of  a 
rabbit  bleach  in  eight  minutes  after  section  of  the  cervical  spinal  marrow,  and 
to  have  then  examined  the  other  eye,  which  had  been  shaded,  and  found  the 
colour  of  normal  brightness.  Boll  also  claims  to  have  seen  the  retinal  red 
with  the  ophthalmoscope,  in  the  eye  of  the  guinea-pig,  and  says  that  in  all 
the  mammalia  the  characteristic  colour  can  be  detected  in  this  way  until 
twelve  hours  after  death,  and  thinks  this  fact  might  be  of  use  in  medico- 
legal cases.  In  his  opinion  there  are  three  factors  concerned  in  the  pro- 
duction of  the  red  reflex  from  an  eye-ground  viewed  with  the  ophthalmo- 
scope. They  are  :  1.  The  Erythropsine.  2.  The  blood  in  the  choroidal 
vessels.  3.  The  red  in  the  artificial  light  generally  used.  The  last  factor 
could  of  course  be  eliminated  by  using  white  or  monochromatic  light.  Boll 
perceives  a  great  difference  in  the  depth  and  intensity  of  the  colour  of  the 
human  retina  according  to  whether  it  is  examined  immediately  after  a 
night's  sleep  or  late  in  the  day,  and  on  this  bases  an  experiment  for  the 
subjective  demonstration  of  the  retinal  red.  He  says  that  if  upon  first 
waking  in  the  morning,  in  a  dark  room,  the  eyes  are  exposed  for  a  moment 
to  bright  sunlight  and  instantly  closed  again,  the  whole  field  of  vision  will 
appear  of  a  lively  red,  intersected  with  the  spider's-web-like  outlines  of  the 
capillaries,  and  marked  by  the  macula  lutea,  of  a  ferruginous  tint.  All  this 
presently  fades,  but  the  verification  may  be  obtained  several  times  before 
the  colour  finally  becomes  too  faint  to  be  distinguished.  Dietl  and  Plenk, 
however,  deny  the  possibility  of  seeing  the  retinal  red  with  the  ophthalmo- 
scope. They  say  there  is  nothing  of  the  kind  to  be  seen  in  the  frog,  and 
this  observation  is  amply  confirmed  by  our  own  experiments.  We  found 
the  image  of  the  flame  thrown  on  the  retina  to  be  grayish-white,  and, 
except  in  the  bloodvessels,  no  trace  of  colour  visible.  Yet  the  same  mem- 
brane, removed  from  the  eye,  always  showed  the  proper  tint  in  profusion. 
Kiihne  endeavours  to  explain  this  by  showing  that  lake-coloured  fluids 
cannot  be  distinguished  from  black  if  placed  on  a  dark  background.  He 
says  that  a  drop  of  blood  made  lake-coloured,  and  placed  on  black  paper, 
cannot  be  distinguished  from  a  drop  of  ink  by  its  side.  Boll,  however, 
claims  that  the  red  can  be  seen  in  situ  in  the  frog's  eye  by  emptying  out 
the  refractive  media,  and  looking  at  the  retina  obliquely  with  the  ophthal- 
moscope. This  does  not  agree  with  our  own  observations,  for  the  only 
colour  we  have  been  able  to  obtain  in  this  way  was  in  spots  where  the 
pigment  layer  had  been  accidentally  detached,  and  light  shown  through 
the  sclera  and  retina  from  behind.  The  pigment  layer  is  so  dense  in  the 
frog's  eye  as  to  render  the  parts  covered  by  it  perfectly  opaque. 

Dietl  and  Plenk  took  a  rabbit,  which  had  been  kept  in  the  dark,  bound 
up  its  eyes  and  injected  milk  in  one  carotid  while  they  bled  from  the  other. 
The  ophthalmoscope  now  showed  the  retina  of  a  pure  white.  They  then 
injected  blood  again  until  the  eye-ground  was  red  from  filling  of  the  cho- 
roidal vessels.  Fifteen  minutes  later  the  retina,  examined  on  a  ground- 
glass  slide,  was  found  to  be  of  a  pale  red.  Coccius  took  the  extirpated 
eye  of  an  ox,  which  had  been  kept  in  the  dark  an  hour  before  death,  punc- 
tured it  a  few  lines  behind  the  cornea,  and  introduced  a  probe.  Where 
this  probe  touched  the  retina  the  ophthalmoscope  showed  a  ring  of  red 
surrounding  it.    If  a  little  fold  of  the  retina  was  pushed  up,  a  streak  of  red 


1878.]    Retinal  Red  and  its  Relation  to  the  Sensation  of  Sight. 


195 


appeared,  which  vanished  again  when  the  retina  became  smooth.  If  the 
retina  was  turned  slightly  round,  the  purple  appeared  in  abundance.  A 
trial  of  the  same  method  in  a  live  rabbit  resulted  in  the  same  way.  In 
this  case,  the  retina  becoming  torn,  effused  blood  obscured  the  eye-ground 
except  in  one  place  where  the  proper  colour  was  plainly  visible.  The 
writer  has  made  a  number  of  experiments  on  human  beings  by  excluding 
the  light  from  one  eye  for  several  hours  with  a  bandage,  while  the  other 
eve  of  the  same  person  was  left  free.  Subsequent  ophthalmoscopic  examina- 
tions always  failed  to  show  any  difference  of  tint  between  the  two  retinas. 

Boll  and  Kiihne  have  both  investigated  the  effect  of  monochromatic 
light  upon  the  retinal  colour.  The  former  found  that  red  light  intensified 
the  hue  at  first,  and  caused  it  to  fade  very  slowly.  Under  this  illumina- 
tion the  microscope  showed  the  green  rods  in  the  frog's  retina  becoming 
brighter.  Yellow  light  affected  both  the  red  and  green  rods  very  slowly. 
Green  light  acted  quickly  on  the  red  rods,  but  apparently  caused  the  green 
ones  to  increase  in  number.  Blue  and  violet  rays  acted  like  green.  Under 
their  influence  the  number  of  the  green  rods  was  apparently  doubled,  and 
they  remained  plainly  visible  for  some  time  after  the  red  ones  became 
colourless.  Ultra  violet  rays  had  no  effect  on  the  colour  of  the  rods.  Kiihne 
also  observed  that  the  grass-green  rods  in  the  frog's  retina  do  not  bleach 
in  green  light.  He  placed  on  a  screen  a  sufficient  number  of  frog's  retinas 
to  cover  the  entire  solar  spectrum,  and  exposed  them  simultaneously  to 
its  influence.  The  bleaching  commenced  in  greenish-yellow,  and  passed 
successively  through  yellowish-green-,  green,  bluish-green,  greenish-blue, 
blue,  indigo,  and  violet  ;  later  through  pure  yellow  and  orange  ;  much  later 
through  ultra  violet,  and  finally  through  red.  Rabbits'  retinas  bleached 
most  quickly  in  the  part  of  tin;  spectrum  between  D  and  E.  He  found 
that  the  human  retina  bleached  in  blue  to  violet  in  12  minutes,  in  green 
in  2.3  minutes,  while  in  red  the  colour  lasted  8  hours.  Ewald  and  Kiihne 
afterwards  repeated  the  experiments  on  frogs'  retinas  with  results  slightly 
varying  from  the  foregoing.  They  conclude,  however,  that  the  bleaching 
commences  at  the  line  E  of  the  spectrum,  and  advances  through  green 
and  blue  to  violet  ;  then  commences  in  yellow,  and  passes  through  orange, 
red,  ultra  violet  and  ultra  red.  Under  green,  however,  although  the  reti- 
nal purple  quickly  changes  to  yellow,  the  complete  decomposition  takes 
place  afterward  more  slowly.  Under  violet,  on  the  contrary,  the  change 
to  yellow  is  made  very  sloAvly  ;  but  once  accomplished,  it  quickly  fades  to 
white.  So  that  traces  of  yellow  may  still  be  seen  under  the  green  rays 
after  all  colour  has  disappeared  under  the  violet.  From  this  they  infer 
that  visible  light  acts  on  the  retinal  red  with  varying  intensity,  according 
to  the  colour  of  the  rays,  and  that  the  wave  lengths  which  most  quickly 
change  the  retinal  purple  to  retinal  yellow  act  most  slowly  on  this  latter, 
while  those  waves  which  have  least  effect  on  the  purple,  act  most  quickly 
in  changing  the  retinal  yellow  to  retinal  white. 

The  regeneration  of  the  retinal  red  is  not  due  to  the  circulation  of  the 
blood  in  the  vessels.  Kiihne  found  that  if  a  frog's  eye  is  cut  out,  opened 
and  exposed  to  the  light,  the  colour  is  reproduced  for  some  time  as  well  as 
if  the  eye  were  in  its  proper  place  in  the  living  body.  -If  the  posterior 
half  of  such  an  eye  is  pulled  and  twisted  so  as  to  throw  the  retina  into 
folds,  and  the  light  is  then  allowed  to  shine  upon  it,  the  retina  will  be 
found  after  removal  from  the  eye  to  be  white  where  the  folds  were  but  red 
as  to  the  other  parts.  If  a  frog  is  placed  in  the  sun  for  several  hours, 
and  the  eyes  are  then  removed,  the  retinas  will  be  found  completely 


196 


11  E  V  I  E  W  S  . 


[July 


bleached ;  but  if  one  of  these  eyes  is  laid  in  the  dark  for  an  hour,  and 
then  examined,  it  will  have  regained  its  colour.  If  the  retina  is  carefully 
loosened  from  a  lateral  half  of  the  posterior  portion  of  a  frog's  eye,  and  a 
thin  scale  of  porcelain  is  inserted  to  prevent  the  membrane  from  coming 
in  contact  with  the  parts  beneath,  and  the  whole  is  then  subjected  to  the 
action  of  light,  the  raised  half  will  be  quickly  bleached.  If  the  porcelain 
scale  is  now  removed,  the  retina  replaced  in  position,  and  the  eye  put  in 
the  dark  for  a  few  minutes,  the  membrane  will  regain  its  colour.  A  piece 
of  the  retina  may  even  be  cut  out  and  allowed  to  bleach  on  a  plate,  but 
if  carefully  replaced  in  position  in  the  eye  the  colour  is  quickly  restored. 

Ewald  and  Kiihne  made  further  investigations  in  this  direction,  and 
found  that  if  a  retina,  free  from  pigment  cells,  is  held  in  the  light  until 
bleached,  and  is  then  placed  in  the  dark,  it  will  regain  its  colour  in  an 
hour  or  so.  This  experiment  may  be  several  times  repeated  with  the 
same  retina.  If  bleached  in  the  living  eye,  however,  the  colour  cannot 
be  restored  in  this  way.  If  the  retina  is  removed  from  the  eye  with  its 
pigment  cells  attached,  the  regeneration  of  the  red  is  still  more  pro- 
nounced ;  but  in  neither  of  these  cases  is  it  so  perfect  a*  when  the  retina 
is  laid  back  in  the  eye.  We  have  verified  most,  if  not  all.  of  these  re- 
sults with  the  retina  of  the  frog  {Rana  temporaria).  Ewald  and  Kiihne 
state  that  the  solution  of  retinal  purple  in  ox  gall,  previously  mentioned, 
also  possesses  the  power  of  regenerating  its  colour  in  the  dark,  and  attri- 
bute this  faculty  to  a  substance  which  they  suppose  to  be  secreted  by  the 
pigment  cells,  and  which  they  name  Rhodophyllin.  The  pigment  cells 
macerated  in  solution  of  gall  yield  a  purple  of  peculiar  intensity.  Boll 
considers  that  the  minute  yellow  globules  found  in  the  pigment  layer  of 
the  frog  are  feeders  or  reservoirs  of  retinal  red.  When  frogs  are  kept  in 
the  dark  all  the  globules  are  equally  coloured.  But  if  a  frog  is  put  in  the 
sunlight  until  its  retina  is  bleached,  and  it  is  then  kept  in  the  dark  for  an 
hour,  many  of  the  globules  will  be  found  to  be  pale,  and  numbers  of  them 
quite  colourless. 

That  the  pigment  cells  manufacture  the  retinal  red  is  supported  also  by 
anatomical  considerations.  It  is  well  known  that  these  cells  send  down 
fine  filamentary  processes  into  the  interstices  of  the  rods  and  cones,  and 
these  processes  seem  to  be  contractile  and  influenced  as  to  their  length  by 
the  amount  of  light  thrown  upon  them.  Boll  has  shown  that  the  re- 
tina is  most  easily  separable  from  the  pigment  layer  in  eyes  which  have 
been  kept  in  the  dark  or  in  red  or  yellow  light.  It  cannot  be  removed 
without  tearing  or  without  masses  of  pigment  clinging  to  it  from  eyes 
which  have  been  subjected  to  white,  green,  or  blue  light.  When  eyes  of 
the  former  class  have  been  hardened  in  alcohol,  the  microscope  shows  that 
the  interstices  of  the  rods  are  free  from  pigment ;  while  the  latter  class 
treated  in  the  same  way  exhibit  cordons  of  pigment  extending  to  the 
base  of  the  rods  at  the  membrana  limitans  externa,.  With  regard  to  the 
structure  of  the  rods  and  cones,  Boll  claims  that  the  external  segments 
are  really  composed  of  very  thin  plaques,  of  which  the  plaques  described 
by  Schultze  (.0005  mm.  thick)  are  merely  groups  containing  a  greater  or 
less  number.  The  real  plaques  are  designated  by  fine  transverse  lines  on 
the  fresh  rods,  seen  orly  by  an  immersion  objective,  and  very  favourable 
illumination.  Fracture  is  always  determined  by  these  lines  at  right  angles 
to  the  axis  of  the  rods. 

Kiihne  had  no  sooner  taken  his  first  optogram  than  he  proceeded  to 
construct  a  theory  of  vision  based  on  his  observations.    He  thinks  that 


1878.]    Retinal  Red  and  its  Relation  to  the  Sensation  of  Sight.  197 


the  light  waves  are  transformed  in  the  retina  into  chemical  action  by  means 
of  the  purple  which  gives  rise  to  different  products  for  each  colour.  These 
products  would,  of  course,  affect  the  terminal  nerve  filaments  each  in  its  own 
manner.  He  believes  that  there  may  be  other  photo-chemical  substances 
in  the  retina  besides  the  purple.  Even  before  the  retinal  red  was  dis- 
covered, however,  Hering  had  called  attention  to  some  facts  which  seemed 
to  indicate  the  existence  of  such  a  substance.  The  first  of  these  facts  is 
the  phenomenon  which  he  called  successive  luminous  induction,  and  con- 
sists of  the  spontaneous  formation  of  an  areola  of  light  around  the  negative 
image  of  a  bright  object.  Another  effect  is  seen  when  the  line  of  separa- 
tion between  a  white  and  a  black  surface  is  steadily  regarded.  At  first 
both  colours  appear  more  intense  {simultaneous  contrast), .but  soon  this  effect 
disappears  and  after  a  moment  each  partakes  of  the  colour  of  the  other 
{simultaneous  induction).  From  these  facts  he  infers  that  the  action  of 
light  is  not  limited  to  the  retinal  elements  directly  subjected  to  its  rays. 
He  was  thence  led  to  form  a  physico-chemical  theory  of  vision,  as  the  only 
probable  one,  and  to  suppose  that  the  retina  contained  three  different  photo- 
chemical materials,  which  he  chose  to  call  the  white-black,  the  yellow-blue, 
and  the  red-green  substances.  He  thought  that  all  the  effects  of  light  and 
shade,  and  colour  might  be  produced  by  the  assimilation  or  disassimilation 
of  these  three  materials.  He  gave  additional  force  to  these  suggestions 
by  the  remark  that  the  hitherto  received  theory  of  retinal  fatigue  is  dis- 
proved by  the  consideration  that  the  negative  image  of  a  bright  object  on 
a  dark  background,  developed  in  the  closed  eyes,  never  attains  the  black- 
ness of  the  negative  image  of  the  same  object  developed  on  a  lighter  field. 

But  though  these  theories  evidently  point  in  the  right  direction,  there 
are  yet  some  facts  which  encourage  the  belief  that  the  writing  on  the  finger- 
board is  not  quite  correct,  as  a  guide  to  the  road  we  must  follow  if  we  wish 
to  find  out  the  mystery  of  vision.  Most  birds,  for  example  the  pigeon 
and  chicken,  have  no  retinal  colour.  Minute  red  balls  exist  in  the  cones 
of  the  central,  aid  yellow  in  those  of  the  peripheral  parts  of  their  retinas; 
but  although  we  exposed  such  retinas  for  an  hour  or  more  to  the  direct 
action  of  the  sun's  rays,  the  tint  of  the  balls  underwent  apparently  no 
change.  The  retinas  of  snakes  and  lizards  consist  entirely  of  cones  and 
contain  no  red.  Kiihne  was  unable  to  find  any  retinal  purple  in  man  at 
the  fovea  centralis  or  macula  lutea,  and  for  2  mm.  around  the  latter  the 
colour  was  very  faint.  The  red  disappears  in  front  at  from  3  to  4  mm. 
behind  the  ora  serrata.  At  best,  the  rods  only  are  coloured,  the  cones  are 
colourless.  Frogs,  in  which  the  retina  has  been  bleached  by  exposure  to 
sunlight,  catch  flies  as  well  as  ever.  In  such  frogs  the  retina  does  not 
regain  its  colour  for  thirty  minutes  at  least,  but  if  during  this  time  a  fly 
commences  to  buzz  around  near  them  and  alights  anywhere  within  striking 
distance  it  is  instantly  snapped  up.  Coccius  found  that  rabbits  with 
bleached  retinas  saw  perfectly  well. 

The  writer  has  the  temerity  to  suggest  that  perhaps,  after  all,  the  retinal 
red,  as  we  find  it,  is  only  the  excess  of  photo-chemical  substance  which  in 
the  intervals  of  active  vision  is  stored  up  in  the  rods  for  future  use.  When 
the  sight  is  being  constantly  exercised,  no  colour  can  be  detected.  Prob- 
ably the  only  parts  of  the  rods  and  cones  capable  of  appreciating  light  are 
the  extreme  tips  in  contact  with  the  pigment  cells,  where  the  retinal  red  is 
generated.  The  large  flat  ends  of  the  rods  would  only  be  susceptible  to 
large  impressions  as  compared  with  the  slender  cone  points.  These  last 
give  us  precision  of  detail  just  as  we  can  more  accurately  measure  a  dis- 


198 


Reviews. 


[July 


tance  with  compasses  than  with  the  fingers.  In  the  eccentric  parts  of  our 
retinas,  where  the  rods  much  outnumber  the  cones,  we  get  only  general 
impressions  of  objects.  But  to  obtain  accurate  definition  of  parts  we  must 
focus  the  rays  on  the  crowded  cone  tips  of  the  fovea  centralis.  The  calcu- 
lations of  Volkmann  showed  that  the  smallest  retinal  image  which  could  be 
perceived,  irrespective  of  circles  of  dispersion  was  .0002"  in  diameter; 
while,  according  to  Schultz,  the  cone  tips  of  the  fovea  are  4^t  (.000148") 
apart.  Behind  this  region  of  distinct  vision  the  pigment  cells  are  more 
abundant  than  in  any  other  part  of  the  retina,  and  this  insures  a  constant 
and  ample  supply  of  the  visual  photo-chemical  substance  just  where  it  is 
most  wanted,  at  the  most  used  part  of  the  retina.  Why  the  red  should  be 
absorbed  by  the  rods  and  not  by  the  cones  might  possibly  be  accounted  for 
by  the  broad  absorbent  surfaces  which  the  former  offer  to  the  pigment  cells  ; 
while  the  cones  present  an  array  of  sharp  points,  more  likely  to  repel  than 
to  attract. 

It  is  after  all  not  so  certain  that  there  is  no  retinal  red  at  the  macula 
lutea,  for  Schmidt-Rimpler  reported  nearly  two  years  ago  that  in  perfectly 
fresh  human  eyes,  taken  either  from  the  body  immediately  after  death  or 
removed  during  life,  he  found  the  macula  lutea  of  a  dark  reddish-brown 
colour.  This  spot  of  colour  gradually  grows  smaller,  the  well-known  yel- 
lowish hue  taking  its  place.  The  yellow  tint  first  forms  a  zone  surround- 
ing the  decreasing  reddish-brown  spot,  and  encroaches  on  the  space  occu- 
pied by  the  latter  as  it  contracts,  so  that  the  last  speck  of  red  is  to  be  seen 
at  the  centre  of  the  fovea.  This  red  colour  of  the  macula  does  not  depend 
upon  the  choroidal  vessels  showing  through,  for  the  retina  is  no  thinner 
here  than  elsewhere,  indeed,  according  to  Schultz,  it  is  thicker.  Besides 
the  colour  goes  with  the  retina  when  it  is  pushed  about  over  the  choroid. 
Even  the  exceptional  cases  of  birds  and  reptiles,  which  have  no  retinal 
red  but  only  coloured  globules  in  the  rods  and  cones,  become  less  exceptional 
in  the  light  of  the  investigations  of  Capranica.  He  found  these  globules, 
which  are  of  various  shades,  from  ruby-red,  through  orange  and  yellow,  to 
colourless,  to  exhibit  three  characteristic  reactions.  1.  Sulphuric  acid 
turns  them  dark  violet,  changing  to  dark  blue.  2.  Nitric  acid  turns  them 
greenish-blue,  quickly  becoming  colourless.  3.  A  0.25  per  cent,  solution 
of  iodine  turns  them  bright  green,  passing  to  greenish-blue.  The  coloured 
globules  in  the  pigment  layer  of  the  frog's  retina  exhibit  the  same  behaviour 
to  these  reagents.  This  leads  Capranica  to  suppose  that  the  only  differ- 
ence existing  among  these  globules  arises  from  the  various  degrees  of  con- 
centration of  the  colouring  matter.  All  the  globules  are  soluble  in  ethylic, 
amylic,  or  methylic  alcohols,  in  ether,  chloroform,  benzine,  and  sulphuret 
of  carbon.  These  solutions  are  yellow,  except  the  last,  which  is  red.  The 
spectroscope  gives  an  absorption  band  at  the  line  F  and  another  between 
F  and  G.  Light  has  more  or  less  effect  in  decolourizing  the  solutions. 
Now  all  these  tests  are  the  same  in  result  as  those  relied  upon  to  distinguish 
the  substance  which  Hoppe-Seyler  and  Thudicum  have  described  under 
the  name  of  luteine,  and  which  is  found  in  the  yolk  of  eggs,  in  the  yellow 
bodies  of  the  ovaries,  serum  of  blood,  etc.  It  appears  to  stand  in  a  paren- 
tal relation  to  the  Erythropsine  of  Boll,  and  suggests  the  thought  that 
even  before  the  eye  is  created  the  substance  upon  which  vision  depends  is 
already  in  existence.  H.  S.  S. 


1878.J 


199 


ANALYTICAL  AND  BIBLIOGRAPHICAL  NOTICES. 

Art.  XX. — Saint  Bartholomew* s  Hospital  Reports.  Edited  by  W.  O. 
Church,  M.D.,  and  Alfred  Willett,  F.R.C.S.  Vol.  XIII.  8vo.  pp. 
xxiv.,  354,  126.    London:  Smith,  Elder  &  Co.,  1877. 

From  1865,  the  date  of  issue  of  the  first  number  of  this  excellent  series,  up  to 
the  present  time,  eaeli  year  has  witnessed  the  publication  of  a  volume,  fairly  and 
adequately  representing  the  vast  experience  gathered  by  the  medical  staff  or 
former  pupils,  within  the  walls  of  the  venerable  St.  Bartholomew's.  Vol.  XIII. 
ably  sustains  the  reputation  earned  by  preceding  numbers  ;  it  contains  twenty-eight 
papers,  of  which,  some  are  purely  surgical  while  others  are  more  particularly 
interesting  to  physicians.    We  will  consider  the  medical  papers  first. 

In  the  first  article,  on  Presystolic  Murmurs  at  the  Heart's  Ape^  by  Dr. 
James  Andrews,  the  author,  though  holding  that  all  cardiac  murmurs  produced 
at  the  auriculo- ventricular  openings  must  be  either  systolic  or  diastolic,  that  is, 
the  current  either  passing  into  or  out  of  the  ventricles,  retains  the  term  "pra3sys- 
tolic,"  as  sanctioned  by  long  use;  restricting  it, 'however,  to  a  murmur  occurring 
during  the  last  part  of  the  ventricular  systole.  The  characters  which  he  gives  to 
such  a  murmur  are — 

"  That  its  point  of  greatest  intensity  is  a  little  within  and  above  the  apex  beat; 
it  fades  towards  the  left  axilla,  and  is  not  heard  behind.  A  diastolic  thrill  is 
present  over  the  left  ventricle.  The  murmur  has  a  peculiar,  harsh,  droning 
sound,  and  becomes  louder  towards  its  close,  which  is  abrupt.  It  is  generally 
difficult  to  distinguish  an  interval  between  it  and  the  first  sound.  The  first  sound 
is  shortened  and  intensified.  Reduplication  of  the  first  sound  is  of  frequent  oc- 
currence. The  second  sound  is  very  feeble,  or  entirely  absent  at  the  apex ;  the 
second  sound  is  intensified  at  the  left  base,  and  very  frequently  reduplicated. 
The  physical  signs  of  dilatation  of  the  left  auricle  and  of  the  right  side  of  the 
heart  are  present.  The  murmur  varies  much  in  loudness,  length,  and  pitch  ;  may 
disappear  entirely  or  even  be  replaced  by  a  systolic  apex  murmur.  These 
changes  are  of  common  occurrence  as  the  case  approaches  its  termination.  The 
pulse  is  often  small,  rapid,  and  very  irregular." 

These  symptoms  Dr.  Andrews  believes  to  be  equally  characteristic  of  mitral 
stenosis  and  mitral  roughening.  The  fact  that  in  some  cases  of  presystolic  mur- 
mur the  second  sound  is  very  feeble,  or  even  entirely  absent  at  the  apex,  though 
heard  at  the  base,  is  advanced  by  the  author  in  support  of  the  fanciful  theory 
originally  proposed  by  Gendrin,  which  attributes  the  second  sound  of  the  heart  to 
"the  sudden  entry  of  blood  into  the  ventricle  during  its  diastole,"  a  position  in 
which  we  are  inclined  to  think  he  will  find  few  supporter's. 

The  second  paper,  by  Dr.  J.  Wickham  Legg,  On  the  Essential  Phenomena 
of  Jaundice,  is  the  continuation  of  the  series  commenced  in  the  last  volume  of 
these  Reports  by  the  author,  and  exhibits  his  extended  knowledge  with  the  bib- 
liography of  the  subject,  the  major  part  of  his  article  being  the  statement  of  the 
views  of  others.  According  to  Dr.  Legg,  the  coloration  may  appear,  usually 
first  in  the  conjunctiva,  within  twenty-four  hours  after  obstruction,  though  even 
then  the  urine  will  give  a  good  reaction  with  Gmelin's  test.  The  other  mucous 
membranes,  except  the  part  under  the  tongue,  as  first  noticed  by  Hippocrates, 


200 


Bibliographical  Notices. 


[July 


do  not  exhibit  the  yellow  colour,  though  they  can  be  made  to  look  jaundiced  by 
pressing  away  the  blood,  and  allowing  the  colour  of  the  tissues  beneath  to  show 
through.  The  secretions,  with  the  exception  of  the  urine,  as  stated  by  the  au- 
thor, rarely  show  the  presence  of  bile  pigment,  though  the  assertion  hardly  ap- 
pears sustained  by  the  number  of  instances  he  has  reported  in  which  the  pigment 
was  found  by  various  observers  in  the  different  secretions,  more  particularly  in 
the  sweat.  He  has  also  noticed  that  croupous  exudations  contain  bile  pigment 
more  frequently  than  catarrhal,  while  the  serous  exudations  first  show  its  pres- 
ence. Dr.  Legg  does  not  agree  with  Frerichs  as  regards  the  frequency  with 
which  jaundice  is  accompanied  by  constipation,  and  states  that  he  has  most  often 
found  diarrhoea  in  simple  acute  jaundice,  by  which,  probably,  he  refers  to  catarrh 
of  the  bile-ducts,  in  which  case  it  would  be  natural  to  expect  diarrhoea  from  the 
common  participation  of  the  intestines  in  the  catarrh,  while  in  the  chronic  cases, 
when  the  intestinal  catarrh  has  subsided,  we  would  expect  constipation,  from 
absence  of  bile,  the  natural  cathartic,  a  condition  which  agrees  both  with  Dr. 
Legg's  experience  and  French's  statement  as  to  constipation  being  the  rule. 
Albumen  is  rarely  absent,  and  sugar  rarely  present  in  the  urine.  The  analyses 
which  Dr.  Legg  has  made  of  the  urine  of  ten  cases  of  jaundice  have  not  thrown 
much  light  on  the  vexed  question  of  the  relative  proportions  of  urea  in  the  healthy 
and  jaundiced  urine;  his  observations  simply  show  that  in  jaundice  the  urea  may 
be  reduced,  natural,  or  greatly  in  excess. 

In  an  article  entitled  Brief  Xotcs  on  the  Outbreak  of  Scurvy  in  the  late  Arctic 
Expedition,  Mr.  Harry  Leach  has  contributed  a  well- written  abstract  of  the 
evidence  given  before  the  "Arctic  Committee"  appointed  by  the  Admiralty  to 
investigate  the  circumstances  attending  the  disastrous  outbreak  of  scurvy  alluded 
to  in  the  title.  Every  one,  we  think,  will  acknowledge  that  scurvy  is  a  disease 
which  should  never,  in  these  days,  be  seen  in  any  civilized  community,  except 
in  times  of  Avar  or  famine,  and  that  it  should  occur  in  an  expedition  absent,  from 
start  to  return,  only  a  little  over  one  year,  and  supplied  without  stint  with  every- 
thing that  science  or  art  could  direct, — that  scurvy  should  appear  under  such 
circumstances,  is  naturally  calculated  to  awaken  suspicions  of  ignorance  or  neglect 
on  the  part  of  either  the  medical  or  executive  officers.  Let  us  see  what  bearing 
the  facts  detailed  by  Mr.  Leach  would  exert  upon  this  impression.  The  expedition, 
consisting  of  a  complement  of  122  men  for  the  two  vessels,  the  Alert  and  the 
Discovery,  started  in  the  summer  of  1875  ;  the  winter  was  spent  to  a  great  ex- 
tent in  darkness,  the  sun  not  being  seen  from  the  Alert  for  142  days,  and  from 
the  Discovery  for  138.  The  breathing  space  allotted  to  the  men  on  the  Alert 
was  107,  and  on  the  Discovery  140  cubic  feet ;  various  analyses  of  the  atmosphere 
between  decks  on  the  Alert  showed  a  proportion  of  0.3314  per  cent,  of  carbonic 
acid,  or  more  than  five  times  the  maximum  amount  in  a  sufficiently  pure  air,  and 
on  the  Discovery  0.415  per  cent,  or  nearly  seven  times  as  much  as  the  maximum 
quantity.  It  is  also  stated  that  a  great  amount  of  dampness  constantly  prevailed 
between  decks,  and  that  there  was  a  deficient  supply  of  fresh  meat,  the  men  on 
the  Alert  having  rations  of  it  on  only  53  days,  and  on  the  Discovery  only  14 
days.  No  case  of  scurvy,  however,  is  reported  as  having  occurred  during  the 
winter,  except  in  one  instance,  a  hard  drinker,  and  the  conclusion  is  therefore 
drawn  by  the  author  that  the  men  were  in  good  health  at  the  end  of  this  j>eriod, 
a  conclusion  unwarranted  by  the  facts  of  the  case.  For  several  weeks  previous  to 
the  departure  of  the  sledging  parties,  lime-juice  was  served  out  to  the  men  in 
double  quantities.  The  sledge  diet  contained  an  excess  of  8.21  ounces  of  water- 
free  solids  over  the  ship  diet,  the  excess  being  largely  made  up  by  an  increase  in 
the  quantity  of  fat.  In  the  ship  diet,  vegetables  were  represented  by  preserved 
potatoes,  issued  in  rations  of  eight  ounces  once  or  twice  a  week,  and  of  four  ounces 


1878.] 


Saint  Bartholomew's  Hospital  Reports. 


201 


four  times  a  week  ;  other  compressed  vegetables  in  rations  of  two  and  six  ounces 
respectively  twice  a  week,  while  vegetables  were  present  in  several  of  the  tinned 
meats.  There  was,  besides,  a  daily  ration  of  one  ounce  of  lime-juice  (all  authori- 
ties agree  that  less  than  four  ounces  has  no  antiscorbutic  value),  increased  on 
board  the  Alert  to  two  ounces  during  March.  In  the  sledge  scale  of  rations  vege- 
tables are  represented  by  only  two  ounces  of  preserved  potatoes,  while  in  no  in- 
stance ivas  lime-juice  systematically  given. 

"  Such  were  the  dietary  conditions  under  which  the  sledge  expeditions  were 
organized,  and  58  cases  of  scurvy  out  of  the  60  occurred  in  men  who  had  been 
deprived  for  a  greater  or  less  period  of  adequate  vegetable  material  in  their  food. 
Practically  they  had  lived  without  vegetables,  or  its  substitute,  lime-juice.  Some 
of  this  juice  was  indeed  carried  by  two  or  three  of  the  minor  sledge  parties,  espe- 
cially by  those  which  started  from  the  ships  towards  the  latter  part  of  the  sledging 
season,  or  visited  the  depot  where  lime-juice  was  stored.  But,  as  we  know,  it 
was  not  given  systematically  in  any  case,  and  the  sledge  parties  which  suffered 
most  severely  from  scurvy  were  not  provided  tvith  it."    (Italics  are  ours.) 

Under  such  circumstances  it  is  not  surprising  that  scurvy  should  have  appeared. 
No  one,  probably,  now-a-days  will  question  the  fact  as  to  the  deprivation  of  fresh 
vegetable  food  being  the  invariable  antecedent  of  scurvy,  while  the  position  of 
lime-juice  as  an  anti-scorbutic  is  equally  assured.  And  yet  we  have  here  the 
statement  of  a  reduction  in  vegetable  food  and  the  cessation  of  the  administration 
of  lime-juice — the  actual  deliberate  creation  of  the  cause  and  removal  of  the 
antidote  of  a  disease  under  circumstances  in  which  all  former  experience  had 
shown  its  appearance  most  to  be  expected  and  dreaded. 

Instead,  however,  of  finding  resolutions  of  censure,  certainly  merited,  by  those 
who  had  the  responsibility  of  organizing  this  expedition,  we  find  the  tame  and 
puerile  conclusion,  "arrived  at  by  the  Committee  and  indorsed  by  the  Admiralty, 
was,  that  'the  early  outbreak  of  scurvy  in  the  spring  sledging  parties  of  the  expe- 
dition was  due  to  the  absence  of  lime-juice  from  the  sledge  dietaries'"  (p.  47), 
and  "it  was  agreed,  however,  and  with  some  show  of  reason,  that  lime-juice 
cannot  be  carried  in  sledging  expeditions  so  as  to  be  given  systematically,  accord- 
ing to  the  scale  above  mentioned"  (p.  46),  and  that,  too,  in  the  face  of  the  state- 
ment made  on  p.  44,  that,  in  the  sledging  parties  "in  the  cases  of  the  '  North 
Star, '  '  Pioneer, '  and  '  Intrepid, '  the  medical  evidence  goes  to  prove  that  the 
immunity  from  scurvy  was  due  to  the  regular  serving  out  of  lime-juice,  with 
frequent  rations  of  fresh  meat  and  vegetables."  (Italics  ours.)  It  is  also  stated 
on  the  same  page  that  ' '  there  is  good  reason  to  believe  that,  with  some  few  excep- 
tions, the  disease  appeared  in  a  greater  or  less  degree,  i.  e.  where  no  anti-scorbu- 
tics were  carried  and  taken  systematically."  In  this  connection,  it  is  interesting 
to  note  that  Mr.  Leach  quotes  from  a  Blue  Book  published  under  the  auspices  of 
the  Board  of  Trade  only  two  years  ago  (Pari.  Paper.  117,  1876),  in  which  the 
outbreak  of  scurvy  in  several  instances  in  the  merchant  marine  is  attributed  to 
the  eating  of  "  scouse,"  i.  e.,  a  mixture  of  cook's  fat,  biscuit,  and  water,  to  which 
minced  salt  meat  is  usually  added.  We  think,  liowever,  with  Mr.  Leach,  that  it 
would  be  difficult  to  prove  that  any  of  these  articles  were  either  directly  or  indi- 
rectly scorbutic  in  their  effects,  nor  do  we  think  it  likely  that  this  "  Official  Ke- 
port"  will  have  any  marked  influence  on  the  views  long  held  as  to  the  causation 
of  scurvy.  It  is  also  to  be  noticed  that  as  contributions  (?)  to  our  knowledge  of 
the  prophylaxis  of  scurvy,  the  Admiralty  recommend  the  "  carrying  of  eggs," 
"fresh  meat,  or,  as  its  best  substitute,  preserved  meat ;"  "vegetables  rank  high- 
est in  anti-scorbutic  value,"  while  rum  is  acknowledged  inferior  to  tea,  and  some 
concentration  of  lime-juice,  such  as  lozenges,  is  recommended  as  more  portable. 
These  are  the  outlines  of  the  abstract  made  by  Mr.  Leach  of  this  Blue  Book, 
which  he  thinks  ' 4  undoubtedly  furnishes  the  most  complete  scientific,  as  well  as 


202 


Bibliographical  Notices. 


[July 


practical,  essay  on  scurvy  that  exists  at  the  present  time."  Accepting  Mr.  Leach's 
abstract  as  correct,  we  cannot  but  consider  the  expedition  as  a  disastrous  failure 
in  every  respect,  and  the  Report  a  discredit  to  English  literature. 

The  next  article  is  by  Dr.  W.  Henry  Kesteven,  and  is  entitled  Further 
Researches  on  the  Pathology  of  the  Nervous  System.  In  a  paper  published  in  the 
last  volume  of  these  Reports  the  author  described  the  degenerative  changes  met 
with  in  disease  of  the  cerebrospinal  nervous  system  ;  the  present  paper  is  con- 
cerned with  the  atrophic  changes  found  in  the  nerve  cells,  nerve  fibres  and  neu- 
roglia, and  alterations  in  the  bloodvessels.  In  commencing  atrophy  of  the  nerve 
cells  the  first  change  the  author  noticed  was  the  appearance  between  these  bodies 
and  the  neuroglia  of  a  gradually  increasing  space,  accompanied  by  degeneration 
of  the  nucleus,  whose  apparent  increase  of  size  he  states  is  due  to  the  wasting  of 
the  corpuscle.  In  a  later  stage,  the  corpuscular  processes  shrink  and  finally  dis- 
appear through  loss  of  their  axis  cylinders,  or  they  may  remain  as  simple  fibres. 
The  final  stages  resemble  pigmentary  degeneration  and  are  usually  associated  with 
vascular  disturbances.  Atrophy  of  nerve  fibre  is  usually  associated  with  sclerosis 
of  the  neuroglia,  so  that  upon  cross  section,  instead  of  showing  its  regular  spiral 
arrangement,  the  axis  cylinders  may  appear  crumpled  or  even  entirely  disappear, 
leaving  a  round  or  oval  hole  which  may  ultimately  be  filled  up  by  hypertrophied 
neuroglia,  increased  at  the  expense  of  the  nerve  structure  proper.  In  some  cases 
of  general  nervous  atrophy,  as  from  external  pressure,  there  may  be  a  decrease  ot 
all  the  nerve  elements.  Atrophy  of  the  neuroglia  is  always  associated  with 
atrophy  of  the  other  nervous  elements,  and  is  characterized  by  disappearance  ot 
or  excessive  decrease  of  the  normal  number  of  its  nuclei.  Among  the  alterations 
in  the  bloodvessels,  Dr.  Kesteven  alludes  to  aneurisms  in  nervous  tissue,  and  the 
cause  of  formation  of  the  perivascular  spaces.  The  former,  according  to  the 
author,  are  most  frequently  seen  on  the  convex  surfaces  of  the  loops  at  the  margin 
of  the  spinal  cord  and  at  the  lower  part  of  the  anterior  fissure.  The  perivascular 
spaces,  Dr.  Kesteven  believes,  when  found  in  nervous  tissue,  to  be  of  morbid  crea- 
tion, caused  through  atrophy  of  the  nerve  elements  from  pressure  by  distended 
vessels,  the  post-mortem  emptying  and  contraction  of  which  leave  spaces  surround- 
ing them.  While  possibly  these  views  may  be  correct,  though  in  direct  contra- 
diction of  the  statement  of  His,  and  though  they  appear  to  be  substantiated  by  the 
fact  that  Key  and  Retzius  were  unable  to  inject  them  either  from  the  bloodvessels 
or  lymphatics,  the  observations  of  Kolliker,  Virchow,  Yon  Recklinghausen, 
Arnold,  and  Foa  have  demonstrated  the  existence  of  perivascular  serous  channels 
in  other  structures,  though  even  this  fact  has  been  questioned  by  Tarchanoff, 
and  it  seems  possible  that  future  experiments  may  show  the  presence  of  perivas- 
cular serous  channels  in  the  nervous  system.  The  paper  is  illustrated  by  six 
excellent  lithographs. 

Dr.  Kesteven  has  also  contributed  another  paper  on  The  Structure  and 
Functions  of  the  Olivary  Bodies.  Several  points  in  this  article  are  worthy  of 
notice.  In  the  first  place,  after  describing  the  well-known  coarse  appearance  of 
these  bodies,  i.  e.,  the  inferior  olives,  we  find  him  repeating  the  statement  origi- 
nally made  by  Lenhossek  and  Schroeder  v.  d.  Kolk,  but  since  disproved  by  Clarke, 
Fry,  Meynert,  etc.,  of  the  connection  of  the  inferior  olives  with  the  fibres  of  the 
hypoglossal  nerve,  a  connection  on  which  he  bases  part  of  his  theory  of  function. 
On  the  other  hand  it  appears  from  the  description  that  the  fibres  which  Dr.  Kes- 
teven considers  as  commissural  between  the  nerve  cells  of  the  two  olives,  really 
belong  to  the  outermost  and  middle  fibrce  arctuatoz  described  by  Meynert,  which 
pass  from  the  restiform  body  through  the  nucleus  of  the  5th  nerve,  in  part 
through  and  in  part  behind  the  olivary  body  of  the  same  side,  without  however 
any  connection  with  its  nerve  cells,  and  out  of  its  hilus  and  into  the  hilus  of  the 


1878.] 


Saint  Bartholomew's  Hospital  Reports. 


203 


olivarv  body  on  the  opposite  side  with  whose  cells  it  does  connect.  The  external 
white  cortex  of  the  olivary  body,  according  to  the  author,  consists  of  two  layers 
of  fibres  derived  from  the  cells  of  the  gray  matter  of  these  bodies  :  the  external 
layer  is  derived  from  the  internal  corpuscles  of  the  convolutions,  some  of  whose 
processes  converge  and  pass  out  of  the  hilus  :  of  these,  some  pass  down  the  me- 
dulla, diverging,  after  winding  around  the  superior  margin  of  the  olive,  thus 
agreeing  with  the  course  of  the  fibres  of  the  stratum  limnisci  which  Burdach  has 
described  as  the  funicule  olivce :  others  of  these  fibres,  which  the  author  states 
pass  downwards  and  inwards,  are  evidently  that  portion  of  the  jibroz  arctuatce 
which  Stilling,  Lenhossek,  Schroeder,  Clarke,  and  more  especially  Deiters,  have 
described  as  the  anterior  division  by  which  the  inferior  olives  are  connected  with 
the  restiform  bodies  on  the  opposite  side,  thus  forming  part  of  the  same  system  to 
which  the  fasciculi  cuneatus  and  gracilis  and  posterior  fibraj  arctuatee  belong. 
The  interna!  layer  of  the  cortex,  Dr.  Kesteven  states  is  formed  by  fibres  from  the 
external  corpuscles  of  the  convolutions,  the  fibres  passing  from  before  backwards 
in  a  direction  at  right  angles  to  that  of  the  external  layer,  thus  agreeing  with  the 
fibres  which  Meynert  has  described  as  the  most  posterior  of  the  fibras  arctuata3.  On 
the  strength  of  the  communication  which  the  author  states  to  exist  between  these 
bodies  and  the  5th,  8th,  and  9th  nerves,  he  considers  that  the  olivary  bodies  are 
the  co-ordinating  centres  for  the  movements  of  deglutition. 

The  three  following  medical  papers  are  by  Dr.  Samuel  Gee.  In  the  first  ot 
these  Dr.  Gee  calls  attention  to  the  possible  causation  of  Pneumonia  by  Disease 
of  tli e  Tracheal  and  Bronchial  Glands,  and  details  four  cases  in  which  such  dis- 
ease- was  followed  by  perforation  or  compression  of  the  adjoining  bronchus  with 
subsequent  gangrenous  or  ulcerative  pneumonia. 

In  the  next  article  Dr.  Gee  describes  as  Spastic  Paraplegia  a  disease  "cha- 
racterized by  constant  rigidity  of  the  legs,  or  of  the  legs  and  arms,  which  increases 
when  the  limbs  are  handled,  and  disappears  under  the  use  of  chloroform." 
Among  other  attributes,  he  states  that  the  lesion  is  congenital,  or  occurs  in  early 
infancy  ;  the  affected  muscles  are  well  nourished  and  respond  to  faradism.  ISTo 
tremors;  intellect  and  sensation  normal;  no  lesion  of  micturition;  general 
nutrition  good  ;  back  weak  in  all  cases  ;  chorea  in  two  cases  of  the  four  he 
reports,  convulsions  in  two,  painful  cramp  of  the  legs  in  one  case.  Dr.  Gee,  also, 
in  a  Contribution  to  the  History  of  Polydipsia,  narrates  the  rather  curious  instance 
of  eleven  patients,  all  members  of  the  same  family,  and  representing  four  gene- 
rations, being  afflicted  with  diabetes  insipidus.  In  two  instances  the  disease  was 
congenital ;  in  several  cases  members  of  one  generation,  who  had  escaped  the 
family  disorder,  transmitted  it  to  their  children ;  two  cases  are  reported  as  having 
outgrown  their  disorder. 

The  next  medical  paper  is  a  well-written  essay  on  Fibrinous  Exudation  into 
the  Bronchial  Tubes,  by  Dr.  F.  De  Haviland  Hall,  with  full  notes  of  one 
case.  Under  the  title  of  Cases  bearing  on  Diseases  of  the  Liver,  Dr.  J.  Wick- 
ham  Legg  has  reported  two  cases  of  cirrhosis  occurring  in  children,  in  neither 
of  which  any  symptoms  occurred  to  direct  attention  to  the  liver  before  death. 
The  symptoms  in  one  case,  a  boy  aged  12,  closely  resembling  typhoid  fever  or 
tuberculosis  ;  while  the  other,  an  infant  aged  17  months,  showed,  with  the  addition 
of  purging,  symptoms  only  of  tuberculous  meningitis.  Post-mortem  examination 
in  both  cases  showed  cirrhosis ;  the  bibliography  is  given  of  cases  of  cirrhosis  in 
children.  In  alluding  to  the  so-called  "  Movable  or  Displaced  Liver,"  the  author 
mentions  a  case  in  which  all  the  symptoms  described  as  being  present  in  cases  of 
displaced  liver,  such  as  the  absence  of  the  normal  hepatic  dulness  and  the  presence 
of  a  tumour,  resembling  the  liver,  in  some  other  situations,  were  present  in  a  case 
under  his  charge,  which  post-mortem  examination  revealed  to  be  a  case  of  tumour 


204 


Bibliographical  Notices. 


[July 


of  the  right  kidney,  the  liver  being  in  its  normal  situation,  and  even  increased  in 
size.  From  the  fact  that  tympanitic  bowels  or  emphysematous  lungs  may  conceal 
the  hepatic  dulness,  while  many  abdominal  tumours  might  resemble  the  liver  in 
physical  characteristics,  and  from  the  fact  that  none  of  the  reported  cases  were 
confirmed  by  autopsy,  one  being  disproved,  the  author  thinks  that  in  view  of  the 
improbability  of  sufficient  relaxation  of  the  hepatic  ligaments,  a  movable  liver  is 
an  anomaly  whose  existence  remains  still  to  be  proved.  He  also  reports  a  case  of 
supposed  primary  melanotic  cancer  of  the  liver. 

The  next  paper  is  entitled  Medical  Cases,  by  Samuel  West,  M.B.,  and 
contains  the  history  of  three  cases  of  fever  with  diarrhoea  ;  in  two  of  which 
ulcerations  were  found  in  the  large  intestines  ;  in  one  there  was  an  abscess  of  the 
liver.  The  clinical  histories  strongly  resemble  typhoid  fever,  from  which,  how- 
ever, they  are  separated  by  the  absence  of  the  characteristic  eruption  and  post- 
mortem lesions  ;  Mr.  West  also  states  that  the  ulcerations  did  not  resemble  those 
of  dysentery.  Two  cases  of  pneumothorax  from  tubercular  phthisis  are  reported, 
and  two  cases  of  anaemia  in  which  the  microscopic  appearances  of  the  blood  resem- 
bled those  of  pernicious  anaemia.  One  case  recovered.  The  same  author  next 
describes  a  case  of  Hypertrophic  Cirrhosis,  occurring  in  a  child  3  years  old,  trace- 
able to  a  severe  scald  and  characterized  by  chronic  icterus  with  exacerbations, 
attended  by  hepatalgia,  fever,  enlargement  of  liver,  and  gradually  increasing 
icterus.  Persistent  enlargement  of  liver,  no  ascites,  no  dilatation  of  abdominal 
veins,  death,  with  symptoms  of  "icterus  gravis."  Post-mortem  examination 
showed  the  case  to  be  one  of  "hypertrophic  cirrhosis,"  with  its  characteristic 
development  of  new  bile-ducts.    The  report  is  illustrated  with  a  plate. 

Dr.  Dyce  Duckworth  contributes  a  paper  on  The  JEtiology  of  Mitral  Ste- 
nosis, with  deductions  from  264  cases,  80  of  which  are  tabulated,  the  main  points 
of  which  are  that  he  found  a  rheumatic  origin  in  CO  per  cent.  ;  females  are  affected 
more  often  than  males ;  the  average  age  of  all  cases  being  about  30  years, 
while  the  mitral  valve  is  sometimes  affected  in  children  in  the  course  of  the 
exanthemata. 

Mr.  P.  Kidd  contributes  an  interesting  case  of  Great  Enlargement  of  Pons, 
Crura  Cerebri,  and  Medulla,  and  Mr.  John  Abercrombie,  A  Case  of  Spas- 
modic Rigidity  with  Idiocy.  The  last  article  in  the  volume  is  an  extremely  elabo- 
rate paper  by  Dr.  Lauder  Bruntox  and  Mr.  D'Akcy  Power  on  The  Albu- 
minous Substances  which  occur  in  the  Urine  in  Albuminuria.  No  abstract  that 
we  could  make  would  give  any  adequate  idea  of  the  contents  of  this  contribution, 
and  we  regret  that  we  have  not  space  to  notice  it  at  length. 

This  number  contains  also  the  Proceedings  of  the  Abernethian  Society,  and 
terminates  with  the  Statistical  Report  of  the  Hospital  Cases  for  18  7  7,  compiled 
by  the  Registrars, and  occupying  127  pages.  R.  M.  S. 

We  shall  next  notice  the  surgical  papers  in  their  order. 

Mr.  Francis  Henry  Champneys  presents  an  account  of  a  dissection  of  a 
Case  of  Extroversion  of  the  Blaelder  in  a  Female  Child.  It  is  a  model  descrip- 
tion ;  full,  but  not  diffuse,  concise,  yet  not  obscure.  After  a  description  of  the 
dissection,  and  a  sufficient  comparison  with  a  number  of  other  similar  eases,  lie 
discusses  the  theories  of  the  causation  of  such  defects,  grouped  under  three  heads  : 
1.  Mechanical;  2.  Pathological;  3.  Developmental.  He  concludes,  as  seems 
most  probable,  that  it  is  due  to  an  arrest  of  development,  and  dates  from  before 
the  third  week  of  intra-uterine  life.  A  very  useful  partial  bibliography  is  ap- 
pended ;  a  growing  custom  we  most  heartily  commend. 

The  same  author  next  relates  a  Case  of  Interstitial  Fibro-myoma  of  the  Uterus, 
which  complicated  delivery.    ISTo  symptom  of  its  presence  previous  to  the  sixth 


1878.] 


Saint  Bartholomew's  Hospital  Reports. 


205 


month  of  pregnancy  had  ever  been  observed.  Natural  labour  being-  impossible, 
turning  was  resorted  to,  and  after  the  use  of  much  force  a  dead  foetus,  weighing 
of  pounds,  was  extracted.  A  few  days  after  delivery,  an  offensive  discharge  and 
constitutional  septic  symptoms  set  in,  the  temperature  rising  to  102°,  for  which 
carbolized  injections,  ergot,  and  quinia  were  used.  The  tumour  gradually  sub- 
sided, five  weeks  after  delivery  it  was  found  projecting  at  the  vulva,  and  was 
removed.  The  mass  was  as  large  as  the  fist.  Her  symptoms  at  once  improved, 
and  about  three  weeks  later  she  left  the  hospital.  A  brief,  but  instructive  discus- 
sion of  similar  cases  follows. 

As  Intolerance  of  Light  is  almost  as  universal  a  symptom  of  diseases  and  inju- 
ries of  the  eye  as  lameness  is  of  diseases  and  injuries  of  the  leg,  the  title  of  Mr. 
B.  J.  Vernon's  paper  might  afford  free  scope  for  quite  an  extended  treatise. 
The  author  has,  however,  confined  himself  principally  to  phlyctenular  keratitis, 
sympathetic  ophthalmia,  and  hysterical  asthenopia. 

The  paper  would  have  done  very  well  as  a  lecture  to  medical  students,  but,  as 
it  contains  no  original  observations  and  no  suggestions  in  pathology  or  therapeu- 
tics that  may  not  be  found  in  the  text-books  of  ophthalmic  surgery,  it  is  not  very 
clear  why  the  author  felt  impelled  to  contribute  it  to  the  reports. 

Mr.  Henry  J.  Butlin'S  paper  is  on  Fatty  Tumours  in  Infancy  and  Child- 
hood. On  account  of  their  great  rarity  the  two  cases  which  he  records,  the  only 
two  in  tour  and  a  half  years  in  the  large  number  of  patients  at  St.  Bartholomew's, 
are  valuable,  although  in  themselves  they  were  not  remarkable.  One  in  a  child 
of  twelve  years  lay  over  the  left  sterno-niastoid  muscle,  and  was  said  to  have  ap- 
peared at  nine  years  of  age.  It  was  first  believed  to  be  glandular.  The  other 
patient  was  seven  years  old.  The  tumour  was  situated  in  the  calf,  and  had  been 
first  noticed  a  year  after  birth.  It  was  removed  with  difficulty,  as  it  extended 
between  the  bones  to  the  front  of  the  leg.  The  operation  was  followed  by  pyaemia, 
but  after  amputation  of  the  thigh  the  child  recovered.  Most  of  these  tumours 
are  encapsulated,  and  contain  a  larger  proportion  of  fibrous  tissue  than  similar 
lipomata  in  adults.    Several  similar  cases  are  briefly  quoted. 

Mr.  E.  L.  Hussey  next  gives  a  case  of  Aneurism  in  the  Gluteal  Region  after 
a  Punctured  Wound.  An  intemperate  man,  a3t.  53,  was  struck  by  his  wife  with 
a  short,  broad  dagger  in  the  gluteal  region.  Copious  bleeding  followed,  but  ceased 
spontaneously,  and  he  went  to  his  work  the  next  day.  The  wound  soon  healed,  but 
three  or  four  weeks  afterwards,  on  rising  from  his  chair,  he  felt  a  pain  at  the  part, 
and  found  a  small  swelling.  Two  months  later,  it  was  as  large  as  a  small  orange; 
six  weeks  later  still,  it  was  three  times  as  large,  and  he  was  compelled  to  give  up 
work  and  submit  to  treatment.  An  aortic  clamp  was  applied,  and  by  an  incision 
eight  inches  long,  from  the  anterior  crest  of  the  ilium  towards  the  middle  of  the 
sacrum,  the  aneurism  was  laid  open,  and  by  two  fingers  the  bleeding  was  con- 
trolled. The  tourniquet  had  slipped  from  its  place  as  the  man  lay  on  his  right 
side,  and  about  a  pound  and  a  half  of  blood  were  lost.  The  slit  in  the  artery  was 
soon  discovered,  and  a  ligature  applied  on  each  side  of  it.  From  the  sixth  to  the 
fifteenth  day  secondary  hemorrhage  occurred  some  six  times,  but  was  always  con- 
trolled by  ligature  or  pressure.  He  died  on  the  sixteenth  day  from  exhaustion. 
On  examination,  it  was  found  that  the  wounded  artery  was  the  large  descending 
branch  of  the  gluteal.  The  procedure  advocated  by  Mr.  Syme  was  the  only  one 
practicable  in  this  case,  though  it  seems  to  have  been  followed  not  intentionally, 
but  because  the  sac  was  accidentally  opened. 

The  treatment  of  the  pedicle  in  cases  of  ovariotomy  seems  never  to  lose  its 
interest,  although  its  discussion  has  been  carried  to  the  nth  power,  and  accord- 
ingly Mr.  Alb  an  Doran  writes  on  Complete  Intra-peritoneal  Ligature  of  the 
Pedicle.    After  relating  a  few  recorded  cases,  in  several  of  which  this  method 


206 


Bibliographical  Notices. 


[July 


was  adopted  (the  credit  of  which  he  gives  appropriately  to  Dr.  Nathan  Smith,  of 
Connecticut,  in  1821),  he  narrates  briefly  the  post-mortem  results  in  two  cases 
operated  on  by  Dr.  Bantock,  one  of  which  ended  fatally  on  the  sixth  day,  and 
the  other  (from  sarcoma)  after  seven  months.  The  point  he  makes,  and  it  is 
well  taken,  is,  that  the  distal  end  of  the  pedicle  is  saved  from  gangrene  by  adhe- 
sions contracted  with  the  broad  ligament,  through  which  adhesions  it  is  nourished. 
The  ligature  in  the  first  case  was  silk,  in  the  second  hemp,  and  the  latter  had  been 
completely  absorbed. 

By  far  the  most  interesting  surgical  papers  in  this  volume  are  the  next  two. 
The  first  is  by  Mr.  Luther  Holdex  on  a  case  of  Aneurism  of  the  Right  Sub- 
clavian for  which  Amputation  was  performed  at  the  Shoulder-Joint.  Professor 
Spence  in  18G4  (Med.  Chir.  Trans.,  lii.  306)  did  the  first  operation  of  this  char- 
acter. His  patient  lived  for  four  years,  but  the  aneurism  though  diminished  was 
not  cured.  This,  the  second  operation,  was  done  on  a  patient,  a?t.  44,  whose 
aneurism  extended  beneath  the  sterno-mastoid,  the  trapezius,  and  the  clavicle, 
and  had  caused  wasting  of  the  arm  and  severe  neuralgia.  The  aneurism  dated  from 
great  exertion  in  lifting  a  heavy  weight  two  years  before,  when  he  felt  sudden  pain, 
followed  in  a  few  weeks  by  a  swelling  over  the  collar-bone.  As  proximal  ligature 
offered  no  hope  of  success,  the  effect  of  cold  was  first  tried.  Ice  was  "applied  in 
a  bag"  uninterruptedly  for  nineteen  weeks,  the  patient  meanwhile  being  on  half 
diet.  It  would  have  been  better  had  the  method  been  more  accurately  stated. 
The  effects  of  dry  cold  (by  ice  in  a  rubber  bag),  and  of  wet  cold  are  so  very  dif- 
ferent as  to  comfort,  convenience,  efficiency,  and  often  as  to  the  ability  of  a  patient 
to  bear  it,  that  this  should  not  have  been  left  to  conjecture.  Moreover  we  can- 
not but  think  it  an  error  to  continue  this  mode  of  treatment  so  long.  A  shorter 
time  would  have  sufficed  to  show  its  value  or  its  inefficiency,  and  as  at  the  end  of 
the  four  and  a  half  months  it  is  said  that  towards  the  clavicle  the  aneurism  was 
"more  thinned  by  absorption"  and  the  patient  was  "  decidedly  weaker,"  we  can- 
not but  think  that  persistence  was  disastrous.  Next  for  twenty-one  days  three 
pounds  of  small  shot  in  a  bag  were  applied  continuously,  and  the  diet  further 
restricted  to  4  oz.  each  of  bread  and  meat,  and  5  oz.  each  of  milk  and  water  per 
diem,  but  without  result.  Then  for  three  days  simultaneous  compression  of  the 
carotid  and  brachial  arteries  was  employed  for  eight,  ten,  and  eight  hours  respec- 
tively, chloroform  being  given  for  the  last  five  hours.  The  compression  produced 
no  effect  on  the  aneurism,  but  induced  very  great,  and  for  a  time  alarming,  depres- 
sion. Compression  on  the  carotid  sufficient  to  arrest  the  pulsation  produced  syn- 
cope. The  late  Prof.  Dickson  more  than  once  has  shown  the  writer  the  effect  of 
compression  of  one  carotid,  which  would  cause  a  loss  of  over  twenty  beats,  an 
effect,  however,  which  many  experiments  have  shown  not  to  be  true  of  all  persons. 
Eighteen  days  of  full  diet  restored  the  patient's  strength,  and  as  the  aneurism  had 
greatly  increased  and  threatened  a  speedy  and  fatal  rupture  it  was  determined  to 
amputate  at  the  shoulder-joint.  The  axillary  artery  wras  first  tied  through  the 
pectoral  muscles,  and  the  operation  then  completed  "  in  the  usual  way" — presum- 
ably by  the  deltoid  flap.  Pulsation  was  at  once  diminished.  On  the  fifth  day  the 
carbolized  oil  dressing  wTas  abandoned  because  it  produced  sooty  urine.  Except- 
ing a  slight  pneumonia  on  the  fourteenth  day,  he  did  well  till  the  twenty-fourth 
day,  when  the  ligature  came  away.  At  this  time  the  aneurism  became  enlarged 
and  tender,  the  skin  inflamed  and  sloughed,  discharged  offensive  watery  fluid, 
and  on  the  thirty-seventh  day  he  died  from  exhaustion. 

The  post-mortem  showed  an  axillary  abscess,  erosion  ot  the  clavicle,  and  an 
aneurism  of  the  second  and  third  parts  of  the  subclavian  and  first  part  of  the  axil- 
lary, and  a  wide  slit  across  the  upper  surface  of  the  artery  near  its  commencement. 
That  the  slough  was  due  to  the  impaired  vitality  from  the  too  long-continued  use 


1878.]       Transactions  of  the  Obstetrical  Society  of  London.  207 


of  ice  and  pressure  seems  not  doubtful,  and  a  much  earlier  resort  to  amputation 
would  be  justifiable  in  any  similar  case. 

The  other  very  interesting  paper  is  by  Mr.  W.  Morraxt  Baker,  on  The 
Formation  of  Synovial  Cysts  in  the  Leg  in  connection  ivith  Disease  of  the  Knee- 
Joint.  He  relates  eight  most  instructive  cases  which  should  be  carefully  read,  and 
deduces  the  following  important  practical  conclusions. 

"1.  Incases  of  effusions  into  the  knee-joint  and  especially  in  those  in  which 
the  primary  disease  is  osteo-arthritis,  the  fluid  secreted  may  make  its  way  out  of 
the  joint,  and  form,  by  distension  of  neighbouring  parts,  a  synovial  cyst  of  large 
and  small  size.  [The  route  by  which  it  escapes  he  thinks  is  doubtful,  but  it  may 
be  by  the  normal  bursas  of  the  popliteus,  or  the  senii-membranosus,  or  by  a  hernia 
of  the  synovial  membrane.] 

"2.  The  synovial  cyst  so  produced  may  occupy  (a)  the  popliteal  space  and 
upper  part  of  the  calf  of  the  leg,  or  may  (b)  be  evident  in  the  calf  of  the  leg  only, 
projecting  most,  as  a  rule,  in  the  inner  aspect  .of  the  leg,  or  (c)  may  be  percepti- 
ble only  at  the  upper  and  inner  part  of  the  leg  as  a  small  defined  swelling,  not 
approaching  within  three  or  four  inches  of  any  part  of  the  knee-joint. 

•• ;;.  However  large  the  synovial  cyst  may  be,  fluctuation  may  not  be  commu- 
nicable from  it  to  the  interior  of  the  knee-joint ;  but  the  absence  of  such  fluctuation 
must  not  be  taken  to  contra-indicate  the  existence  of  a  connection  between  the  joint 
and  the  cyst. 

"4.  The  synovial  cyst  may  be  expected  to  disappear  after  a  longer  or  shorter 
period  without  leaving  traces  of  its  existence  even  on  dissection  of  the  limb. 

"5.  The  cyst  should  not  be  punctured  [he  does  not  discuss  aspiration,  which 
might  with  great  propriety  be  tried],  or  otherwise  be  subjected  to  operation,  unless 
there  appear  strong  reasons  for  so  doing ;  inasmuch  as  interference  may  lead  to 
acute  inflammation  and  suppuration  of  the  knee-joint. 

"  6.  Most  often  the  disease  in  the  knee-joint  will  be  found  to  have  begun  some 
time  before  the  appearance  of  the  secondary  synovial  cyst ;  but  sometimes  the 
patient's  attention  may  be  first  drawn  to  the  latter,  or  the  cyst  may  seem  for  a 
long  period  the  more  important  part  of  the  disease." 

Curiously  enough  his  drawing  of  Case  II.  represents  a  cyst  on  the  inside  of  the 
left  knee,  while  the  text  describes  it  as  on  the  right. 

Mr.  Fred.  S.  Eve  gives  the  history  of  a  Case  of  Fractures  through  the  Base 
of  the  Odontoid  Process,  from  a  blow  on  the  head.  The  atlas  and  odontoid  were 
dislocated  anteriorly  compressing  the  cord,  yet  the  patient  survived  the  accident 
for  two  and  a  half  hours.  He  adds  eleven  other  cases  (excluding  those  from  shot 
wounds),  and  analyzes  briefly  but  clearly  the  symptoms.  He  recommends  cau- 
tious traction  on  the  head  with  a  slight  inclination  backwards  and  immobilization 
without  a  pillow,  by  sand  bags  with  a  pad  under  the  neck,  or  by  a  splint  (by  far 
the  preferable  plan). 

Dr.  S.  D.  Darbysbtre,  narrates  a  Case  of  Perforating  Ulcer  of  the  Sclerotic, 
in  which  there  were  three  ulcers,  one  of  which  exposed  the  choroid.  They  all 
healed  after  abscission  of  the  other  (left)  eye  for  destruction  of  the  cornea. 

W.  W.  K. 


Art.  XXI. — Transactions  of  the  Obstetrical  Society  of  London.  Vol.  XIX. 
For  the  year  1877.  8vo.  pp.  279.  London:  Longmans,  Green  &  Co., 
1878. 

AVith  an  increasing  fellowship,  now  numbering  over  700,  the  printed  records 
of  this  Society  appear  to  be  gradually  growing  less,  although  there  are  evidences 
of  much  activity  among  the  real  workers.  The  fact  is,  that  the  publications  of  a 
medical  society  are  not  always  the  best  evidences  of  the  grade  of  interest  that  is 


208 


Bibliographical  Notices. 


[July 


manifested  at  its  meetings.  After  some  years  of  existence,  there  is  little  dispo- 
sition in  a  medical  body  to  repeat  its  own  work,  except  where  cases  are  rare, 
peculiar,  remarkable  for  success,  or  give  evidences  of  originality,  either  in  the 
method  of  operating,  or  mode  of  medical  treatment.  "We  know  by  experience 
that  much  of  value  in  medical  discussions,  to  those  in  attendance,  is  necessarily 
lost  to  the  reader,  for  whom  but  a  very  condensed  record  can  be  prepared  by  the 
secretary. 

The  volume  opens  with  the  Report  of  the  Delegate  to  the  Philadelphia  Medical 
Congress,  which  is  quite  a  flattering  and  pleasant  notice  of  our  International 
Medical  Congress,  held  at  Philadelphia  in  1876,  by  the  Society's  delegate,  Dr. 
Robert  Barnes,  who  was  elected  chairman  of  the  Obstetrical  Section.  Dr. 
Barnes  says  : — 

"As  to  the  business  itself,  it  is  difficult  to  express  the  satisfaction  and 
instruction  I  derived  from  the  memoirs  read,  the  able  and  earnest  discussion, 
and  the  deep  interest  which  kept  the  largest  audiences  I  have  ever  seen  at  simi- 
lar meetings  together  from  the  beginning  to  the  end  of  the  proceedings.  There 
were  rarely  less  than  three  hundred  delegates,  members,  and  visitors  present. 
No  social  attractions — and  these  were  many  and  tempting — ever  prevailed  over 
the  earnest  devotion  to  professional  work,  which  had  drawn  by  far  the  greater 
proportion  of  the  medical  men  who  had  thronged  to  Philadelphia  from  every  part 
of  the  United  States  and  Canada. 

"It  would  scarcely  be  becoming  to  dwell  here  upon  the  many  acts  of  kindness 
which  met  me  at  every  step.  The  warmth  of  American  hospitality  is  too  well 
known  to  require  to  be  told  by  me.  The  general  impression  remaining  upon  my 
mind  is  one  of  doubt  as  to  which  country  I  more  especially  belong  to.  It  is  very 
true  that  science  binds  her  votaries  into  one  community ;  but  it  is  also  very  plea- 
sant to  feel  that  this  communion  receives  a  new  charm  from  the  tie  of  personal 
friendship  and  kindred  sympathy." 

Mr.  A.  D.  L.  Napier,  of  Fraserburgh,  X.  B.,  reports  a  Case  of  Trismus 
Nascentium  in  an  infant  five  days  old ;  parents  healthy ;  hygienic  condition 
good ;  funis  separated  the  day  before,  and  cicatrix  quite  healthy ;  labour  easy 
and  natural.  Child  died  in  23  hours;  treated  by  leeching,  and  bromide  and 
iodide  of  potassium.  There  was  no  autopsy.  The  case  is  remarkable  as  an  in- 
stance in  private  practice  in  which  all  of  the  causes  to  which  this  disease  is 
ascribed  were  entirely  wanting. 

Three  Cases  of  Pycemia  in  New-born  Infants  are  reported  by  Dr.  George 
Roper  and  Dr.  Arthur  W.  Edis.  The  first  was  healthy  at  birth;  cord 
separated  on  fifth  day  ;  skin  around  umbilicus  a  little  red.  In  three  or  four  days 
swelling  became  soft,  and  extended  upwards  over  right  clavicle  and  shoulder; 
fluctuated  ;  was  lanced,  and  discharged  healthy  pus.  Child  took  nourishment ; 
bowels  were  opened,  but  became  weaker ;  breathed  with  difficulty ;  abdomen 
began  to  distend,  and  it  died  when  nineteen  days  old. 

Abscess  in  arm  circumscribed,  and  involving  only  subcutaneous  connective  tis- 
sue. No  pleurisy  or  heart  disease.  Peritoneum  reddened  and  injected,  but  no 
lymph  on  surface  except  over  liver.  Umbilical  vein  full  of  pus,  but  no  throm- 
bus ;  phlebitis  extended  along  portal  vein  for  some  distance  into  the  liver. 
Hepatic  vein  and  vena  cava  healthy ;  abdominal  swelling  due  to  distended 
stomach. 

Physician  in  attendance  assisted  in  delivering  a  primipara  with  forceps  two 
days  before  its  death,  and  cut  and  tied  the  cord.  Child  died  in  same  way  on 
fourteenth  day.  No  injury  to  either  mother  or  child.  Mother  died  of  same 
disease  in  two  months,  swellings  having  occurred  in  both  shoulders,  elbows, 
knees,  and  ankles,  and  in  the  toes.  She  had  no  metritis,  peritonitis,  or  tym- 
panites. 


1878.]       Transactions  of  the  Obstetrical  Society  of  London.  209 


The  third  was  a  male  child  of  4  lbs.  10  oz.,  believed  to  be  eight  months. 
Labour  easy  ;  seventh  confinement ;  husband  consumptive ;  two  preceding  chil- 
dren still-born.  Child  blue  and  feeble,  but  nursed  slightly;  died  on  eighth  day. 
Post-mortem. — Tissues  around  umbilicus  much  inflamed;  purulent  deposits  in 
vessels,  but  not  in  liver ;  whole  of  right  thigh  infiltrated  with  serous  fluid  ;  pus 
extending  between  sheaths  of  muscles  ;  femoral  vein  plugged,  and  tissues  slough- 
ing generally  :  abscess  on  region  of  right  shoulder  posteriorly ;  slight  traces  of 
localized  peritonitis. 

The  Annual  Address  of  the  President,  Dr.  Priestley,  is  mainly  a  resume 
of  the  work  of  the  Society  for  the  year,  with  comments  of  his  own  upon  some 
special  points.  He  rates  the  mortality  after  removal  of  fibroid  tumours  of  the 
uterus  by  surgical  proceedings,  at  two-thirds  of  the  cases.  His  remarks  upon  the 
frequent  use  of  the  forceps  in  modern  obstetric  practice  are  made  at  some  length, 
and  he  deprecates  the  tendency  to  indiscriminate  instrumental  interference,  and 
points  out  the  danger  of  recommending  a  general  early  resort  to  forced  delivery, 
because  of  the  want  of  proper  skill  and  carefulness  in  a  large  proportion  of  ob- 
stetric practitioners,  who  require  restraint  to  prevent  them  at  times  from  hurry- 
ing delivery  in  order  to  attend  to  other  calls. 

Dr.  Priestley  is  also  evidently  not  in  favour  of  the  Cesarean  operation  in  cases 
of  cancer  of  the  cervix,  except  where  the  disease  is  very  far  advanced,  and  in- 
volves adjacent  structures.  In  this  opinion  he  differs  from  some  of  his  colleagues, 
who  believe  in  a  very  general  resort  to  the  operation  in  parturition,  where  the  os 
is  dec  idedly  cancerous,  believing  it  to  be  the  best  plan  of  delivery.  The  opera- 
tion has  never,  we  believe,  been  performed  in  the  United  States  for  cancer,  but 
it  has  been  several  times  in  England,  and  the  results  have  been  more  favourable 
than  in  any  other  class  of  subjects. 

Dr.  Priestley  also  condemns  the  growing  disposition  to  early  surgical  inter- 
ference with  tubal  and  abdominal  pregnancies,  and  the  evacuating  of  hemato- 
celes. He  closes  his  address  with  the  usual  notices  of  deceased  fellows,  paying 
a  handsome  tribute  to  the  late  Walter  Channing,  of  Boston,  and  Gustav  Simon, 
of  Heidelberg. 

Mr.  Francis  Ellington,  of  Ontario,  reports  a  case  of  Spontaneous  Inversion 
of  the  Uterus  in  a  multipara  on  the  second  day  after  delivery,  from  the  effects  of 
a  large  dose  of  castor  oil.  given  contrary  to  directions,  by  the  nurse ;  the  uterus 
was  readily  replaced,  and  the  patient  soon  recovered. 

Three  Casts  of  Inversion  of  the  Uterus,  under  Dr.  Greenhalgh,  are  reported 
by  Dr.  Clement  Godson.  1.  Woman  21,  primipara,  inversion  of  five 
months'  standing;  various  attempts  at  replacement  by  Drs.  Greenhalgh  and  God- 
son during  two  months,  failed  ;  amputation  of  uterus  with  6craseur  by  Dr. 
Godson;  patient  made  a  good  recovery.  2.  Woman  31  ;  three  miscarriages  and 
one  child.  Inversion  of  two  years  and  a  half  standing.  Four  attempts  at  re- 
placement during  three  months,  but  all  failed.  Uterus  removed  in  same  way  by 
Dr.  Greenhalgh.  Woman  up  on  fourteenth  day,  and  well  on  22d.  8.  Woman 
28,  single,  one  child.  Inversion  of  same  duration  as  in  Iso.  2 ;  numerous  at- 
tempts, under  most  approved  methods  of  replacement,  failed  ;  uterus  removed  as 
in  other  cases,  and  patient  recovered  without  a  bad  symptom. 

Case  of  Inversion  of  the  Uterus,  Replaced;  by  Dr.  Heywood  Smith. 
Woman  primipara,  set.  30 ;  inversion  of  three  months'  duration.  Pressure  on 
fundus  failing,  it  was  transferred  to  right  cornu,  which  was  gradually  indented,, 
and  the  organ  replaced  in  fifty  minutes.  Dr.  Smith  claims  an  improvement  over 
the  method  of  Noeggerath,  of  New  York,  in  that  he  did  not  first  re-invert  the 
neck,  as  recommended  by  him. 

In  the  discussion  that  ensued  upon  these  reports,  Dr.  Horatio  Storer,  of  Boston, 
No.  CLI  July  1878.  14 


210 


Bibliographical  Notices. 


[July 


took  strong  ground  against  the  operation  of  removal  of  the  uterus,  and  advocated 
the  method  of  slow  replacement,  as  practised  in  some  cases  of  very  long  standing 
with  success,  by  American  gynaecologists. 

rllie  Forceps  in  Modern  Midwifery,  is  the  title  of  an  article  by  Dr.  Arthur 
W.  Edis,  who  is  an  advocate  of  the  long  double  curved  instrument;  believes  in 
the  oscillatory  mode  of  traction  ;  prefers  craniotomy  where  the  foetus  is  dead,  and 
its  head  firmly  impacted  ;  credits  the  instrument  with  saving  life  in  many  instances 
of  protracted  feeble  labour ;  and  claims  an  advantage  in  its  use  as  often  as  one  in 
ten  cases. 

The  discussion  showed  a  great  diversity  of  opinion,  based  on  general  statistics 
and  private  experience,  according  to  the  special  habit  of  the  advocates  of  frequent 
or  rare  use,  as  the  case  might  be.  There  is  a  great  fear  on  the  part  of  many 
obstetricians,  as  evinced  by  the  discussions  that  have  so  frequently  taken  place  in 
medical  societies  upon  this  subject  during  the  last  few  years,  lest  the  recommen- 
dation of  a  more  frequent  resort  to  the  forceps,  by  the  favorable  statistics  of  some 
advocates,  should  work  evil,  rather  than  good,  at  the  hands  of  meddlesome  and 
unskilful  men.  In  a  private  practice  of  two  or  three  thousand  cases  in  a  series  of 
years,  much  will  depend  upon  the  skill  and  care  of  the  physician,  and  a  great 
deal  also  upon  the  class  of  subjects  he  has  had  to  treat.  If  he  has  had  no  cases 
of  syphilis,  ruptured  uterus,  or  deformity  of  pelvis,  he  may  have  had  marked 
success  in  saving  mothers  and  children  with  a  very  seldom  resort  to  the  forceps. 
But  reverse  the  character  of  his  cases,  and  he  will  meet  with  losses  whether  he 
uses  the  instruments  often  or  rarely.  We  met  a  practitioner  recently,  who,  in  a 
practice  of  three  thousand  cases  among  patients  mainly  in  moderate  circumstances, 
and  many  of  them  poor,  had  never  met  with  a  ruptured  uterus,  and  had  only 
been  obliged  to  perform  craniotomy  once.  Another  party,  whose  practice  was 
mainly  among  the  higher  walks  of  life,  with  a  variety  of  experiences  in  defor- 
mities, craniotomies,  cases  of  peritonitis,  and  uterine  exhaustion,  and  who  made 
very  frequent  use  of  the  forceps,  managed  by  carefulness  and  skill,  under  a  fortu- 
nate train  of  circumstances,  to  pass  through  thirty  years  of  his  practice  without 
losing  a  woman  in  labour,  or  from  causes  originating  therein.  Both  of  these  men 
were  very  successful  certainly,  and  from  individual  experience  held  opposite  views 
on  the  question  of  the  necessity  for  the  frequent  use  of  the  forceps.  The  latter 
did  not,  however,  advocate  a  general  frequency  of  resort,  because  he  felt  that 
much  depended  upon  the  character  of  an  obstetrician's  practice,  and  his  delicacy 
in  handling  the  instruments.  He  had  faith  in  his  own  skill,  which  he  certainly 
possessed  in  a  marked  degree ;  but  as  a  teacher  of  students,  felt  the  necessity  of 
caution  in  preaching  what  he  practised. 

This  is  the  position  now  felt  to  be  the  correct  one  by  many  who  do  not  hesitate 
to  use  forceps  frequently,  particularly  in  the  lower  pelvis,  in  feeble  women,  but 
believe  it  to  be  unsafe  to  recommend  frequency  as  a  general  necessity  to  the  pro- 
fession at  large.  As  all  surgeons  are  not  Randolphs  in  the  use  of  the  lithontriptor, 
so  all  accoucheurs  are  by  no  means  Hodges,  in  handling  and  adjusting  the  forceps. 

Dr.  W.  S.  Playfair  reports  cases  of  Fibroid  Tumour  Complicating  De- 
livery. Case  1.  Mrs.  T\r.,  vet.  34;  uterine  fibroid  discovered  in  1870,  in  1872 
it  had  grown  so  as  to  block  up  the  pelvic  caA'ity  and  seriously  interfere  with 
urination,  to  relieve  which,  the  mass  was  pushed  up  out  of  the  pelvis  by  intro- 
ducing the  whole  hand  into  the  vagina.  In  1873  she  married,  much  against  the 
advice  of  her  physician,  and  soon  became  pregnant,  from  which  condition,  and  her 
previous  size,  she  suffered  so  much  as  to  be  confined  to  a  horizontal  position  for 
several  months.  Several  fibroid  masses  as  large  as  cocoanuts  could  be  felt  pro- 
jecting from  the  fundus,  and  one  the  size  of  an  orange,  in  front  of  the  cervix. 

Labor  lasted  fourteen  hours,  pains  normal,  and  no  unusual  suffering,  or  hemor- 


1878.]       Transactions  of  the  Obstetrical  Society  of  London.  211 


rhage,  in  fact  the  tumours  appeared  to  interfere  in  no  way  with  the  process  of 
parturition.  Next  day,  the  contracted  uterus  and  tumours  measured  a  foot  from 
the  symphysis  to  the  fundus.  Six  months  later,  the  uterus  was  nearly  normal  in 
size,  and  the  fibroids  had  almost  entirely  disappeared. 

Case  2.  had  two  globular  fibroids  as  large  as  cocoanuts,  growing  from  fundus 
and  sides  of  uterus.  Pains  feeble  and  infrequent  in  second  stage,  forceps  used, 
child  living,  no  post-partum  hemorrhage.  As  in  No.  1,  the  tumours  almost 
entirely  disappeared  by  absorption. 

Case  3,  is  of  much  value,  as  the  Cesarean  operation  appeared  inevitable,  until 
the  fibroid  was  forced  up  above  the  promontory  of  the  sacrum  by  the  fist  in  the 
vagina,  and  retained  by  bringing  down  the  child's  head  with  the  forceps,  after 
which  the  labor  was  soon  completed ;  the  uterus  contracted  firmly,  and  there  was 
no  hemorrhage. 

Case  4  was  of  the  same  character  as  No.  3,  and  treated  the  same  way.  Child 
presented  by  the  feet,  and  was  still-born. 

This  is  a  very  important  series  of  cases,  as  the  treatment  shows  how  the  Cassa- 
rean  operation  may  be  sometimes  avoided  in  a  condition  in  which  it  is  unusually 
fatal  when  performed. 

Dr.  James  Braithwaite  describes  A  Neiv  mode  of  treating  Certain  Cases  of 
Retroflexion  of  Unimpregnated  Uterus.  The  plan  is  first  to  dilate  the  organ  with 
a  laminaria  tent ;  then  wash  out  the  parts  with  a  weak  iodine  lotion  ;  next 

"Take  a  piece  of  brass  wire  about  eight  or  nine  inches  in  length,  and  no  thicker 
than  can  be  easily  bent  to  a  right  angle  with  the  first  three  fingers  and  thumb  of  the 
right  hand;  one  end  should  be  covered  with  India-rubber  tubing  to  a  length  of 
half  an  inch  less  than  that  of  the  uterine  cavity  as  ascertained  by  the  sound.  This 
must  be  very  securely  and  neatly  closed  at  the  end,  the  end  of  the  wire  being 
inclosed  but  not  included.  The  tubing  should  fit  the  wire  pretty  closely,  and  it 
should  be  firmly  secured  to  it  by  a  strong  hemp  ligature  close  to  its  proximal  end. 
At  this  end  of  the  tubing  is  to  be  placed  a  button,  fixed  to  the  wire,  not  to  the 
tubing.  This,  which  is  the  uterine  end  of  the  instrument,  is  now  to  be  bent  into 
a  curve  somewhat  like  that  of  the  uterine  sound,  the  point  of  the  greatest  curva- 
ture coinciding  with  the  os  internum  when  the  instrument  is  introduced  into  the 
uterus,  which  is  the  next  step.  The  flexion  of  the  uterus  must  then  be  rectified, 
just  as  is  commonly  done  by  the  sound.  An  inflatable  rubber-ball  pessary,  hav- 
ing a  small  central  tube,  is  now  to  be  threaded  on  to  the  wire  projecting  from  the 
vagina,  and  passed  well  up  to  the  os,  in  order  to  retain  the  anteflector  in  the 
uterus  by  its  upward  pressure  against  the  button  when  it  is  inflated  with  air.  The 
wire  projecting  from  the  vagina  is  now  to  be  bent  backward  to  a  right  ano;le  be- 
tween the  buttocks,  so  as  to  lie  closely  in  the  sulcus  between  them." 

Dr.  Braithwaite  keeps  the  woman  in  bed  four  days,  then  washes  out  the  vagina 
with  Condy's  fluid  and  water,  inserts  a  Hodge  pessary,  still  retains  the  patient  in 
bed,  resorts  to  a  large  dose  of  ergot  once  a  day,  and  vaginal  injections  of  cold 
water,  which  he  continues  for  three  days.  He  has  only  tried  the  plan  four  times 
in  as  many  years,  reserving  it  for  extreme  cases. 

This  article  gave  rise  to  a  very  long  discussion  for  and  against  stem  pessaries, 
stem  supports,  laminaria  tents,  etc.,  in  which  the  Hodge  instrument  appeared  to 
be  the  most  commended,  although  there  was  a  great  difference  of  opinion  as  to 
conditions  and  treatment  in  uterine  flexures. 

The  Pathology  and  Treatment  of  Membranous  Dysmenorrhoza  is  the  title  of  a 
very  able  and  valuable  article  by  Dr.  John  Williams,  based  mainly  on  obser- 
vations made  in  fourteen  cases  of  the  disease,  and  a  large  number  of  microscopical 
studies  of  the  membranes  discharged  by  these  and  other  patients.  We  shall  not 
attempt  to  give  any  of  the  cases  in  detail,  but  simply  mention  a  few  remarkable 
facts,  and  the  inferences  drawn  by  the  author. 

Case  1.  A  single  woman  of  30  ;  for  last  three  years  passed  membranes  at  each 


212 


Bibliographical  Notices. 


[July 


period,  and  also  about  the  middle  of  interval,  with  no  hemorrhage  at  the  latter ; 
has  epistaxis  and  hsematemesis  during  and  just  before  menstrual  epoeh,  and  is 
also  subject  to  occasional  convulsions.  Fifteen  membranes  examined.  Those 
passed  in  interval  were  vaginal  only  ;  and  during  menstruation  vaginal  and  ute- 
rine ;  former  tough,  opaque,  whitish,  and  sometimes  gave  a  complete  mould  of 
the  vagina,  with  all  its  superficial  markings ;  latter  brownish,  stained  with  blood, 
incomplete  in  form,  and  presenting  the  structures  usually  met  with  in  decidua. 
Case  2  passed  from  her  uterus  a  flattened  membranous  triangle,  of  a  brownish- 
gray  colour,  stained  with  blood,  measuring  two  and  a  half  inches  in  length,  hav- 
ing a  central  canal  half  an  inch  wide,  and  dividing  off  to  the  two  cornua,  where 
it  was  impervious.  About  twenty-five  membranes  examined.  Case  3  menstru- 
ating for  thirteen  years;  married,  but  sterile;  believed  to  have  always  cast  off"  a 
membrane  at  her  menstrual  period,  and  without  pain,  except  for  the  last  three  or 
four  years.  Case  4  passed  a  complete  triangular  membranous  bag,  with  an  open- 
ing at  each  cornua. 

Treatment  "should  be  prophylactic,"  addressed  to  "those  conditions  which 
are  likely  to  cause  excess  of  fibrous  tissue  in  the  uterine  wall.  Every  means 
should  be  adopted  to  favour  the  physical  development  of  the  young  girl.  The 
puerperal  state  should  be  watched,  and  acute  inflammations  attacked  as  soon  as 
they  arise,  with  a  view  to  favour  complete  resolution.  Once  the  condition  is 
established,  the  only  means  whereby  a  cure  is  likely  to  be  effected,  is  electricity." 
"The  continuous  current  has  proved  successful  in  the  hands  of  SolowiefT." 

Conclusions.  1.  "The  dysmenorrhoeal  membrane  is  not  the  product  of  con- 
ception, but  the  decidua  ordinarily  shed  as  d&bris  with  each  menstrual  epoch." 

2.  "It  is  expelled  as  a  whole  or  in  masses,  in  consequence  of  the  presence  of 
an  excess  of  fibrous  tissue  in  the  wall  of  the  uterus ;  this  excess  is  due  to  imper- 
fect evolution  at  puberty,  imperfect  involution  after  parturition  or  abortion,  or  it 
is  the  product  of  acute  inflammation." 

3.  "The  membrane  is  neither  the  result  of  an  ovarian  congestion,  nor  of  an 
hypertrophy  of  the  ordinary  decidua." 

4.  "The  chronic  inflammation  present  is  usually  the  result  of  the  monthly  ex- 
pulsion of  the  decidua  from  the  uterus,  and  plays  an  accidental  part  only  in  its 
production;  the  inflammation  may,  however,  be  independent  of  the  expulsion  of 
the  membrane,  but  usually  it  has  no  causal  relation  to  the  formation  of  the 
latter. ' ' 

5.  "  Sterility  is  not  necessarily  associated  with  the  affection,  but  is  the  result 
of  the  condition  induced  by  the  expulsion  of  the  membrane  from  the  uterus — in- 
flammation of  the  uterus  and  ovaries." 

6.  "  The  membrane  may  be  expelled  without  pain." 

7.  "  Inflammation  of  the  uterus  greatly  aggravates  the  sufTering  caused  by  the 
passage  of  the  membrane  along  the  cervical  canal." 

8.  "  Great  relief  may  be  obtained  by  curing  the  inflammation  of  the  cervix, 
though  the  membrane  continues  to  be  expelled  every  month." 

9.  "In  order  to  effect  a  cure,  the  structure  of  the  whole  of  the  body  of  the 
uterus  must  be  altered." 

Dr.  Galabin  reports  a  case  of  Suppuration  of  the  Uterine  Cavity  resulting 
from  Occlusion  of  the  Cervix.  It  was  mistaken  for  one  of  ovarian  tumour  be- 
hind the  uterus,  and  the  part  punctured  under  this  belief,  giving  exit  to  a  collec- 
tion of  pus.  The  trocar  opened  the  peritoneal  cavity  on  its  way  into  the  uterus, 
and  set  up  a  general  peritonitis,  of  which  the  woman  died  in  a  few  days. 

The  patient  was  a  widow  of  63,  and  mother  of  eight  children,  who  dated  her 
complaint  from  seven  weeks  before  she  came  under  observation.  Her  uterus 
proved  to  be  sharply  retroflexed,  and  affected  with  cancer  at  the  internal  os. 
which  occluded  the  cervix  and  caused  a  dilatation  of  the  cavity  to  the  size  of  a 
foetal  head,  but  did  not  manifestly  affect  the  external  part  of  the  cervix. 

Forgotten  Pessaries. — Dr.  Galabin  took  out  a  Zwanke  pessary,  which  had 


1878.]       Transactions  of  the  Obstetrical  Society  of  London. 


213 


been  worn  six  years  continuously  by  a  woman  of  58,  in  whom  it  had  produced 
vesico- vaginal  and  recto- vaginal  fistulas.  Dr.  Godson  showed  a  ring  pessary  of 
wood  that  a  woman  had  worn  twenty-six  years  without  being  aware  that  she  carried 
it ;  there  was  no  ulceration.  Dr.  Edis  found  a  Hodge  pessary  in  a  woman  who 
wore  it  eleven  years  without  knowing  it.  The  discussion  showed  the  importance 
of  instructing  patients  to  remove  their  instrument  at  night,  and  replace  it  in  the 
morning. 

Forceps  in  Breech  Presentations  were  advocated  by  Dr.  T.  W.  Agnew,  but 
condemned  by  Dr.  Barnes  as  inefficient  and  dangerous.  He  claimed  that  they 
compress  the  soft  parts  above  the  pelvis  and  the  cord,  which  may  cause  asphyxia. 

Prof.  Tarnier*s  Forceps  were  exhibited  and  explained,  but  did  not  elicit  any 
very  marked  evidences  of  approval,  as  was  also  the  case  when  they  appeared 
before  our  own  Obstetrical  Society. 

On  a  Diagnostic  Sign  of  Vaginal  Hemorrhage  during  Parturition.  By  Dr. 
Paul  Budin,  of  Paris.  Hemorrhages  are  mentioned  as  having  been  noticed  to 
arise  from  ruptured  varicose  veins  of  the  vagina,  from  wounds  of  the  clitoris,  and 
internal  pudic  artery.  These  are  to  be  recognized  by  spots  or  streaks  of  blood 
found  on  the  head  or  neck  of  the  foetus,  while  its  body  occupies  the  cervix  and 
prevents  the  escape  of  uterine  blood. 

On  the  choice  of  the  leg  which  should  be  seized  in  version  for  presentation  of 
the  upper  extremity,  by  Dr.  A.  L.  Galabin.  The  author  confines  his  remarks 
to  cases  where  the  liquor  amnii  has  escaped,  the  uterus  become  contracted,  and 
the  bi-polar  method  rendered  inadmissible.  Dr.  G.,  in  opposition  to  the  views 
of  Sir  James  Y.  Simpson,  Drs.  Barnes,  Tyler  Smith,  Meadows,  and  Playfair, 
advocates  making  traction  on  the  near  foot,  as  upheld  by  Prof.  Martin,  of  Berlin, 
Prof.  Hodge,  Carl  Braun,  Schroe'der,  Leishman,  and  others,  particularly  the 
older  writers ;  and  claims  that  the  method  is  not  only  easier,  but  based  upon  true 
mechanical  principles,  which  he  demonstrates  by  diagrams,  to  show  direction  of 
force  and  rotation  ;  and  calculations,  to  establish  the  mechanical  advantages  of 
the  method  recommended  over  that  of  Drs.  Simpson,  Barnes,  etc.  He  sums  up 
the  advantages  as  follows  :  — 

1.  "  The  rotation  of  the  foetus  on  its  antero-posterior  axis  by  means  of  the 
lower  leg  is  generally  effected  at  a  greater  mechanical  advantage,  and  therefore 
by  a  less  force  than  the  combined  rotation  on  its  transverse  and  longitudinal  axis, 
by  means  of  the  upper  leg ;  while  it  is  sufficient  to  produce  elevation  of  the 
shoulder,  unless  the  foetus  is  dead  and  flaccid,  or  uterine  rigidity  extreme,  and  the 
upper  leg  may  with  no  diminished  advantage  be  afterward  brought  down,  if 
required." 

2.  "If  the  lower  leg  be  taken,  and  the  noose  placed  upon  the  prolapsed  arm, 
the  operator  has  complete  command  of  the  anterior  arm  in  the  subsequent  extrac- 
tion." 

3.  "By  taking  the  lower  leg,  the  more  usual  dors o- anterior  is  not  converted  by 
the  version  into  a  dorso-posterior  position,  a  point  of  very  minor  importance,  but 
one  which  may  in  some  cases  be  worthy  of  consideration." 

Complete  rupture  of  Perineum,  by  Charles  Robert  Thompson.  A  primi- 
para,  set.  22,  in  giving  birth  at  full  term,  to  a  foetus  affected  with  general  dropsy, 
ruptured  her  perineum  in  this  singular  way :  The  head  passed,  and  remained 
during  a  pain  or  two  without  any  advance,  "when  suddenly  the  child's  right 
arm  was  forced  through  the  mother's  anus,  and  in  a  moment,  with  one  long  effort, 
the  body  was  expelled ;  the  forearm  lying  on  the  chest,  plowing  its  way  com- 
pletely through  the  whole  length  of  the  perineum." 

Two  silk  ligatures  were  inserted  at  once,  the  parts  dressed  with  lint  steeped  in 
carbolized  oil,  and  the  patient  placed  on  her  side,  with  her  knees  bandaged 
together.    The  stitches  were  removed  on  the  third  day,  and  bowels  moved  by 


214 


Bibliographical  Notices. 


[July 


an  aperient  on  the  fifth,  the  parts  having  entirely  closed.  The  patient  was  well 
and  about  in  a  month.  The  plan  of  immediate  suturing  the  perineum  in  cases 
of  rupture  is  rapidly  coming  into  favour  as  the  true  method  of  treatment. 

R.  P.  H. 


Art.  XXII. — On  the  Source  of  Muscular  Power:  Arguments  and  Conclu- 
sions drawn  from  Observations  upon  the  Human  Subject  under  Conditions  of 
Rest  and  of  Muscular  Exercise.  By  Austin  Flint,  Jr.,  M.D.,  Prof,  of  Phy- 
siology and  Physiological  Anatomy  in  the  Bellevue  Hospital  Medical  College, 
New  York,  etc.    12mo.  pp.  103.    New  York:  D.  Appleton  &  Co.,  1878. 

Since  Dr.  Mayer,  in  1842,  first  indicated  the  physiological  relations  of  the 
great  discoveries  of  Joule,  Helmholz,  and  Grove  in  the  domain  of  physics,  phy- 
siologists have  earnestly  sought  to  explain  the  hitherto  incomprehensible  phe- 
nomena of  living  beings  by  purely  chemical  and  physical  laws. 

It  is  now  taught  in  many  quarters  that  the  forces  and  laws  of  inorganic  nature 
offer  a  ready  and  sufficient  explanation  of  all  the  subtile  processes  of  organic  life. 
The  simplicity  and  positiveness  thus  introduced  into  the  study  of  vital  phenomena 
has  a  charm  which  is  very  seductive ;  and  if  the  hypothesis  were  only  proven  it 
would  mark  an  era  in  the  history  of  physiology  the  importance  of  which  can 
scarcely  be  realized.  The  investigations  on  the  source  of  muscular  power,  which 
are  recorded  in  the  brochure  before  us,  are  largely  responsible  for  the  material- 
istic tendencies  of  modern  physiology.  It  is  therefore  fortunate  that  Dr.  Flint, 
who  is  so  justly  eminent  as  a  physiologist,  and  who  has  been  one  of  the  principal 
original  investigators  of  the  question  at  issue,  should  enter  the  following  emphatic- 
protest  against  this  tendency  :  — 

"  Taking  nature  as  she  now  appears  to  us,  there  seems  to  be  little  or  no  basis 
for  what  may  be  termed  an  immaterial  physiology.  The  researches  which  I  have 
made  into  the  question  of  the  source  of  muscular  power  are  not  in  any  way  opposed 
to  the  known  relations  between  matter  and  force ;  they  have  been  directed  sim- 
ply toward  the  solution  of  the  problem  whether  the  food  be  concerned  directly, 
by  its  transformations,  in  the  production  of  muscular  power,  or  whether  muscular 
effort  involve  changes  in  the  muscular  substance  itself,  this  substance  being  de- 
stroyed as  muscular  tissue,  discharged  from  the  body  in  the  form  of  excrementitious 
matter,  and  the  waste  being  repaired  by  food." 

The  present  essay  was  originally  printed  in  the  Journal  of  Anatomy  and  Phy- 
siology (Oct.  1877)  ;  and  now,  with  many  typographical  corrections  and  some 
additional  matter,  appears  in  its  present  neat  and  attractive  form. 

The  relation  of  food  to  animal  work  forms  one  of  the  very  interesting  and  im- 
portant chapters  in  physiology,  for,  aside  from  the  purely  scientific  interest  of  the 
problem,  its  solution  must  exercise  a  vast  practical  influence  upon  the  question  of 
alimentation  in  health  and  disease. 

Until  recently,  the  well-known  theory  of  Liebig,  enunciated  nearly  forty  years 
ago,  has  stood  unquestioned  ;  however,  when  the  reactionary  wave  set  in,  it 
rolled  rapidly  to  the  other  extreme,  and  Traube,  with  other  German  physiologists, 
have  advanced  a  theory  directly  opposed  to  that  of  Liebig,  i.  <?.,  that  the  nitro- 
genous constituent  of  muscle  is  not  destroyed  in  its  action,  but  that  the  force  is 
wholly  due  to  the  oxidation  of  non-nitrogenous  matter,  converted,  through  the 
mechanism  of  the  muscular  system,  into  motor  power. 

I  believe  the  new  doctrine  of  the  source  of  muscular  power  numbers  among  its 
supporters  nearly  all  of  the  prominent  foreign  physiologists  ;  in  this  country,  how- 
ever, the  tide  of  opinion  in  its  favour  was  early  arrested  by  the  publication  of  the 


1878.]  Flint,  On  tbe  Source  of  Muscular  Power. 


215 


thoroughly  scientific  experiments  of  our  author  made  upon  the  pedestrian  Weston 
in  1870.  These  experiments,  which  are  analyzed  in  the  volume  before  us,  were 
the  first,  according  to  Dr.  Flint,  in  which  was  adopted  the  method  of  investigating 
the  influence  of  exercise  upon  the  excretion  of  nitrogen  by  comparing  the  nitrogen 
eliminated  with  the  nitrogen  of  food. 

The  attention  of  the  profession  was  first  permanently  directed  to  the  question 
under  discussion  in  1866  by  Profs.  Fick  and  Wislicenus,  in  their  famous  ascent 
of  the  Faulhorn,  one  of  the  Bernese  Alps.  These  distinguished  observers,  though 
their  experiment  lacked  that  scientific  precision  necessary  for  the  establishing  of 
a  great  truth,  assumed  to  have  proven  that  the  muscular  system  is  a  machine  con- 
suming in  its  work  not  its  own  substance,  but  fuel  which  is  supplied  chiefly  by  the 
hydro-carbonaceous  articles  of  food.  Of  the  many  physiologists  who  have  parti- 
cipated in  the  discussion,  the  two  most  prominent  ones,  representing  opposite 
sides  of  the  controversy  as  they  do  different  continents,  are  Profs.  Pavy,  of  Lon- 
don, and  Flint,  of  New  York.  More  than  one-half  of  the  little  volume  before 
us  is  devoted  to  a  discussion  of  the  experiments  of  these  two  observers  upon 
Weston  during  certain  of  his  celebrated  pedestrian  feats.  In  both  series  of  ex- 
periments the  proportion  of  nitrogen  eliminated  to  that  ingested  during  rest  and 
during  extraordinary  exercise  was  ascertained,  although  Pavy  failed  to  include  in 
his  estimate  the  nitrogen  of  the  feces,  which  Flint  considers  an  important  omis- 
sion. Both  experimenters  found  an  increase  of  nitrogen  eliminated  over  that  in- 
gested during  the  days  of  walking,  but  the  interpretation  of  this  increase  leads 
Drs.  Pavy  and  Flint  to  very  different  conclusions. 

AVe  cannot,  for  want  of  space,  give  the  figures  and  calculations  of  our  author, 
but  Dr.  Flint  plainly  shows  that  by  either  method  of  calculation  a  large  dis- 
crepancy exists  between  the  amount  of  work  actually  performed  and  that  which 
can  be  accounted  for  either  by  estimating  the  force- value  of  the  muscle  actually 
consumed,  represented  by  the  nitrogen  excreted,  or  the  force- value  of  the  food 
taken.  In  the  one  case  (Pavy)  the  excess  amounted  to  over  eleven  per  cent,  of 
the  work  actually  done,  while  in  the  other  (Flint)  the  work  accomplished  was 
more  than  ten  times  the  estimated  force-value  of  nitrogenized  food  and  muscle 
consumed,  deducting  the  force  used  in  internal  work  (respiration,  circulation, 
secretion,  etc.).  This  discrepancy  is  only  explicable  on  the  assumption  that  seri- 
ous errors  exist  both  in  the  measurement  of  the  force  produced  and  in  the  calcu- 
lation of  the  force- value  of  matters  consumed.  In  speaking  of  the  data  upon 
which  these  calculations  are  based,  Dr.  Flint  says  : — 

"The  reduction  of  level  miles  walked  to  foot-tons  is  inaccurate;  an  accurate 
estimation  of  the  force  used  in  circulation,  respiration,  etc.,  seems  at  present  im- 
possible ;  and  the  assumption  that  the  force- value  of  nitrogenized  food,  calcu- 
lated by  reducing  heat-units  developed  by  burning  the  food  in  oxygen  to  foot- 
tons,  can  be  applied  absolutely  to  the  changes  which  food  undergoes  in  the  human 
body,  has  no  argument  in  its  favour  drawn  from  experimental  facts.  Still,  no 
one  can  say  that  matter  can  be  actually  destroyed,  that  matter  can  undergo  cer- 
tain chemical  changes  without  the  development  of  force,  or  of  heat  which  repre- 
sents force,  or  that  force  can  be  developed  in  the  body  without  some  change  in 
matter.  My  only  argument  is,  that  purely  physical  laws  cannot  as  yet  be  applied 
absolutely  to  the  operations  of  the  living  organism." 

Dr.  Flint  strongly  and  repeatedly  insists,  in  the  body  of  the  essay,  upon  the 
danger  of  relying  too  implicitly  upon  the  method  adopted  by  Pavy,  Haughton, 
and  others  for  estimating  in  foot-tons  the  force  used  in  circulation,  respiration, 
and  the  production  of  animal  heat. 

When  we  recall  the  fact  that  the  estimates  of  different  observers  of  authority 
present  variations  of  more  than  one  hundred  per  cent.,  we  fail  to  see  how  an 
unprejudiced  mind  can  refuse  to  accept  the  author's  conclusion:   "  I  cannot  see 


216 


Bibliographical  Notices. 


[July 


how  we  can  avoid  banishing,  for  the  present  at  least,  these  uncertain  and  erro- 
neous processes  from  physiological  research,  as  applied  to  the  theories  of  muscu- 
lar action  and  the  source  of  muscular  power." 

The  essay  concludes  with  a  full  and  very  excellent  resume  of  the  argument  in 
the  text,  which  our  limited  space  alone  prevents  us  quoting  in  full.  Injustice  to 
the  reader,  however,  we  cannot  omit  the  following  closing  paragraph  : — 

"  IX.  Finally,  experiments  upon  the  human  subject  show  that  the  direct  source 
of  muscular  power  is  to  be  looked  for  in  the  muscular  system  itself.  The  exer- 
cise of  muscular  power  immediately  involves  the  destruction  of  a  certain  amount 
of  muscular  substance,  of  which  the  nitrogen  excreted  is  a  measure.  Indirectly, 
nitrogenized  food  is  a  source  of  power,  as,  by  its  assimilation  by  the  muscular 
tissue,  it  repairs  the  waste  and  develops  the  capacity  for  work  ;  but  food  is  not 
directly  converted  into  force  in  the  living  body,  nor  is  it  a  source  of  muscular 
power,  except  that  it  maintains  the  muscular  system  in  a  proper  condition  for 
work.  In  ordinary  daily  muscular  work,  which  may  be  continued  indefinitely, 
except  as  it  is  restricted  by  the  conditions  of  nutrition  and  the  limits  of  age,  the 
loss  of  muscular  substance  produced  by  work  is  balanced  by  the  assimilation  of 
alimentary  matters.  A  condition  of  the  existence  of  the  muscular  tissue,  how- 
ever, is,  that  it  cannot  be  absolutely  stationary,  and  that  disassimilation  must  go 
on  to  a  certain  extent,  even  if  no  work  be  done.  This  loss  must  be  repaired  by 
food  to  maintain  life.  A  similar  condition  of  existence  applies  to  every  highly 
organized  part  of  the  body,  and  marks  a  broad  distinction  between  a  living  or- 
ganism and  an  artificially  constructed  machine,  which  latter  can  exert  no  motive 
power  of  itself,  and  can  develop  no  force  that  is  not  supplied  artificially  by  the 
consumption  of  fuel  or  otherwise." 

In  order  to  meet  the  objections  which  might  be  urged  by  some,  that  he  had 
failed  to  include  in  his  calculations  the  heat-producing  and  force-producing  power 
of  the  non-nitrogenous  food  taken  during  the  walk,  Dr.  Flint,  in  a  short  appen- 
dix, supplies  this  omission. 

In  the  experiments  made  on  Weston  in  1870,  the  quantity  of  non-nitrogenous 
food  consumed  was  carefully  Aveighed.  Calculating  the  force- value  of  both  the 
nitrogenous  and  non-nitrogenous  matters  used,  and  adding  the  force- value  of  his 
loss  of  weight,  the  aggregate  represents  the  sum  of  the  forces  with  which  Weston 
was  to  accomplish  his  pedestrian  feat  and  maintain  circulation,  respiration,  etc. 
This  calculation,  however,  fails  to  account  for  the  muscular  work  actually  per- 
formed in  walking  the  three  hundred  and  seventeen  and  one-half  miles  in  five 
consecutive  days.  There  is  still  a  deficiency  of  more  than  ten  per  cent,  which 
cannot  be  accounted  for,  and  which  shows,  according  to  our  author,  "the  fallacy 
of  such  estimates,  and  the  impossibility  of  accounting  for  muscular  work  actually 
performed,  even  when  we  include  the  heat- value  and  the  force- value  of  non-nitro- 
genized  food." 

In  closing  our  imperfect  notice  of  this  monograph,  we  cannot  commend  it  too 
highly  as  an  important  contribution  to  the  literature  of  the  subject  of  which  it 
treats.  It  deserves,  and  doubtless  will  receive,  a  warm  reception  from  the  pro- 
fession. W.  J.  C. 


Art.  XXIII. — Albreclit  von  Graefe:  Sein  Leben  und  WerJcen.     Yon  Dr. 

Eduard  Michaelis,  Augenarzt  in  Berlin.    Berlin:  Druck  und  Verlag  von 

G.  Reimer.    pp.  196,  1877. 
Albrecht  von  Graefe  :  His  Life  and  Works.    By  Dr.  Edward  Michaelis. 

It  is  now  eight  years  since  von  Grafe  died,  and  this  small  volume  is  the  first 
effort  to  acquaint  the  world  at  large  with  the  notable  events  of  his  private  life, 


1878.]    Michaelis,  Albreclit  von  Graefe,  his  Life  and  Works.  217 


and  give  a  connected  resume  of  his  labours  in  his  chosen  field.  His  professional 
life  began  in  1850  and  ended  in  1870,  at  the  age  of  42;  yet  within  that  short 
space  of  twenty  rears  he  made  an  impress  upon  the  medical  spirit  of  his  time  that 
has  no  parallel  in  the  history  of  medicine.  He  found  ophthalmology  as  empirical 
as  an  art  and  as  undeveloped  as  a  science  as  any  other  department  of  medicine ; 
he  left  it  both  as  a  science  and  an  art  far  in  advance  of  all  other  branches.  And 
this  tremendous  stride  is  to  be  attributed  almost  wholly  to  his  own  individual 
labours  or  the  labours  of  those  whom  his  enthusiasm  in  the  study  of  this  branch 
inspired  with  a  desire  to  work  in  the  same  field.  It  is  true  he  was  fortunate  in 
beginning  his  career  just  at  the  time  the  ophthalmoscope  was  invented,  but  even 
without  this  invaluable  instrument  he  would  have  made  himself  felt  in  the  devel- 
opment of  that  specialty  to  which  he  had  determined  to  give  his  powers. 

The  application  of  the  ophthalmoscope  only  gave  him  an  additional  means  to 
carry  out  the  plan  of  study  and  investigation  which  he  had  determined  to  follow — 
a  plan  which  lie  learned  from  Virehow  and  the  French.  This  was  the  careful 
study  of  the  clinical  history  of  each  disease  in  conjunction  with  the  pathological 
alterations  associated  with  it. 

When  he  looked  through  the  first  ophthalmoscope  which  Helmholtz  sent  to 
him.  ''his  eyes  glistened,  his  cheeks  flushed,  and  he  cried  out,  'Helmholtz  has 
opened  a  new  world  to  us.'  "  His  far-seeing  eye  comprehended  at  this  first 
glance  the  richness  of  the  field  that  was  now  for  the  first  time  opened  up. 

To  write  the  life  of  such  a  man  as  this  is  almost  equivalent  to  writing  a  history 
of  the  progress  of  modern  ophthalmology.  There  is  no  branch  of  the  science  to 
which  he  did  not  contribute.  A  great  deal  of  this  work  has  gone  into  our  general 
stock  of  knowledge,  and  the  student  of  to-day  is  not  aware,  in  many  instances,  of 
its  prime  source.  It  is  our  purpose  in  this  article  to  point  out,  as  briefly  as  may 
be  possible,  at  least  the  most  prominent  and  important  additions  he  made  to  the 
science  he  may  almost  be  said  to  have  founded. 

Dr.  Michaelis  has  divided  his  work  into  three  parts,  corresponding  to  the  three 
principal  periods  of  his  life.  1.  His  early  and  student  life,  from  1828  to  1848. 
2.  The  period  of  travel  for  scientific  study,  from  1848  to  1850.  3.  His  profes- 
sional career  in  Berlin,  from  1850  to  1870. 

We  have  time  and  space  for  only  a  hasty  glance  at  the  first  two  divisions. 

His  father  was  Dr.  Carl  Ferdinand  von  Gr'afe,  who  also  worked  in  the  depart- 
ment of  ophthalmology.  He  wrote  several  papers  on  the  subject,  and  published 
in  conjunction  with  Walther  the  "  Journal  der  Chirurgie  und  Augenheilkunde." 
Grate,  the  younger,  however,  does  not  seem  to  have  imbibed  his  love  for  that 
branch  from  his  father.  He  had  his  attention  first  seriously  turned  to  ophthal- 
mology when  he  went  to  Prague  and  saw  Arlt  operating ;  afterwards  it  became 
fixed  when  he  went  to  Paris  and  frequented  the  clinics  of  Desmarres  and  Sichel. 
His  letters  from  Paris  during  this  time  are  highly  interesting.  He  was  very  fond 
of  Parisian  life,  and  his  great  ambition  was  to  establish  himself  as  an  oculist  in 
that  gay  metropolis. 

In  fact,  in  none  of  his  characteristics,  personal  or  professional,  was  he  a  typical 
German ;  and  the  engraved  portrait  which  serves  as  a  frontispiece  to  the  volume 
represents  more  nearly  the  American,  so-called,  than  any  other  nationality.  And 
indeed  in  a  certain  restless  energy  and  tireless  industry  he  did  approach  quite  near 
to  the  characteristic  American  of  to-day.  In  another  particular  he  was  also  con- 
spicuously removed  from  the  average  German  man  of  science.  All  his  labours, 
all  his  investigations,  had  an  eminently  practical  bearing.  When  he  went  into 
theoretical  speculation  at  all  it  was  to  draw  some  important  practical  deduction 
therefrom  for  immediate  application  to  a  case  on  hand. 

In  the  autumn  of  1850  Gi'afe  returned  to  Berlin,  having  completed  his  scientific 


218 


Bibliographical  Notices. 


[July 


travels,  and  proceeded  at  once  to  establish  himself  as  an  oculist  in  that  city.  On 
the  1st  of  November  his  clinic  was  opened.  It  was  in  the  second  story  of  a  small 
unpretending  house  in  Behrenstrasse. 

"  In  one  of  the  front  rooms  there  were  two  tables  placed  together;  on  them 
were  found  small  black  vials  containing  solutions  of  nitrate  of  silver  of  various 
strengths,  one  containing  a  solution  of  acetate  of  lead,  and  two  others  containing 
simple  tincture  of  opium  and  tinctura  opii  crocota.  Sticks  of  nitrate  of  silver  and 
sulphate  of  copper  lay  upon  the  table.  By  the  tables  were  two  chairs,  so  placed 
that  the  one  on  which  the  patient  sat  should  face  the  light,  whilst  Grate's  had  its 
back  to  the  window.  At  some  distance  stood  a  case  containing  a  set  of  Liier's 
eye  instruments.  On  the  other  side  of  the  room  stood  an  old-fashioned  writing-desk 
on  which  prescription  paper  lav.  A  narroAv  corridor  and  a  small  waiting-room 
completed  the  polyclinic.  From  a  tailor  in  Johannesstrasse  were  rented  two  plain 
rooms  with  green  shades,  furnished  with  beds,  bed-curtains,  etc.,  for  the  reception 
of  operated  cases.  Such  was  the  unpretentious  beginning  of  '  Gr'afe's  clinic,'  to 
which  before  the  lapse  of  ten  years  every  country  in  the  whole  inhabited  world 
sent  each  year  its  contingent." 

In  view  of  the  great  fame  this  maison  cle  sant<Z  afterward  attained,  an  incident 
relative  to  the  first  two  patients  operated  on  will  be  of  interest.  The  two  first 
patients  which  occupied  the  beds  in  the  room  rented  from  the  tailor  were  an  old 
blind  organ-grinder  on  whom  he  performed  an  iridectomy,  and  an  old  toper  on 
whom  he  performed  the  operation  of  extraction  of  cataract.  During  the  second 
night  the  old  toper  was  seized  with  delirium  tremens,  and  tore  the  bandage  from 
his  eyes  and  proceeded  to  attack  the  organ-grinder,  beating  him  over  the  head 
and  face  severely.  The  toper  died  in  a  few  days,  but  the  wound  in  the  cornea 
was  found  on  examination  to  be  well  united.  The  or^an-grinder  made  a  good 
recovery,  but  his  first  experience  in  the  hospital  so  frightened  him  that  he  could 
not  be  prevailed  upon  to  submit  the  other  eye  to  operation. 

There  was  nothing  notable  in  his  private  life  apart  from  his  scientific  career. 
He  lived  as  became  a  gentleman  of  fortune,  was  married  in  1861  to  Countess  Anna 
Knuth,  of  Denmark,  and  devoted  himself  and  his  means  to  science  and  humanity. 
Of  commanding,  yet  fascinating  appearance,  his  face  had  so  mild  and  benevolent 
a  look  that  he  was  known  in  the  streets  of  Berlin  as  the  "  Christus,"  such  was  his 
resemblance  to  the  ideal  of  Christ  as  given  to  us  by  the  old  masters. 

His  first  scientific  work  of  importance  was  his  inaugural  treatise  when  he  was 
made  privat  docent  in  the  University  of  Berlin.  Its  subject  was  "  The  action  of 
the  ocular  muscles."  He  it  was  who  first  investigated  the  action  of  the  muscles 
moving  the  eye,  in  healthy  and  in  diseased  conditions ;  and  the  article  above 
mentioned,  his  thesis  when  made  professor  of  ophthalmology  in  the  University  in 
1866,  on  the  "paralysis  of  the  ocular  muscles,"  and  the  first  article  in  the  first 
number  of  his  Archives  on  the  "physiology  and  pathology  of  the  oblique  muscles 
of  the  eye,"  are  among  his  most  important  contributions  to  the  science  of  ophthal- 
mology. 

In  four  years,  the  material  of  his  clinic  had  increased  so  much  that  he  deemed 
it  necessary  to  establish  a  journal,  which  should  enable  him  to  give  to  the  world 
the  fruits  of  his  own  labours,  and  of  those  associated  with  him  in  this  extensive 
field.  Consequently,  in  the  autumn  of  1854  appeared  the  first  number  of  the 
"  Archio  fur  Ophthalmologic,  herausgegeben  von  Dr.  A.  von  Grate."  Of  the 
480  pages,  which  the  first  number  contains,  the  whole  was  written  by  Grafe 
himself,  except  about  86  pages.  Besides  the  article  on  the  oblique  muscles  al- 
ready mentioned,  this  number  contained  important  papers  on  "diplopia  after 
squint  operations  and  incongruence  of  the  retina,"  and  "diphtheritic  conjuncti- 
vitis and  the  employment  of  caustics  in  acute  inflammations." 

The  concluding  chapter  of  the  last  article — on  the  use  of  caustics  in  acute  in- 


1878.]    Michaelis,  Albreclit  von  Graefe,  his  Life  and  Works.  219 


flammation  of  the  conjunctiva — is  exceedingly  important,  since  it  sets  forth  the 
philosophy  of  our  present  routine  of  treatment  of  these  most  common  affections  of 
the  eye. 

The  so  frequent  and  general  application  of  astringents — the  nitrate  of  silver  in 
particular — even  by  general  practitioners  for  blenorrhoea  of  the  conjunctiva,  is 
sufficient  reason,  we  think,  for  quoting  rather  freely  from  this  article,  and  espe- 
cially so  as  in  no  text-book  in  English  has  so  full  an  explanation  of  the  action 
and  indications  for  astringents  been  given. 

"If  a  moderately  strong  solution  of  nitrate  of  silver,  say  x  grs.  to  the  oz.  of 
water,  be  dropped  into  the  healthy  eye,  there  follows  immediately  upon  its  appli- 
cation an  irritation  of  considerable  severity,  varying  very  much  in  different  indi- 
viduals :  the  eye  cannot  be  opened,  it  weeps,  becomes  red  and  hot,  and  there  is  an 
inclination  to  apply  cold  water  for  its  relief.  This  irritation  increases  and  reaches 
its  maximum  in  about  ten  minutes  ;  then  there  appears  a  whitish  secretion.  If  the 
eye  is  opened  at  this  time,  it  will  be  seen  that  the  eschar,  which  originally  covered 
the  entire  mucous  surface  in  the  form  of  a  whitish  mucus,  has  become  loosened  at 
its  edges,  and  is  being  rolled  together;  it  is  this,  together  with  the  tears  and 
the  secretion  of  the  conjunctiva,  which  furnishes  the  whitish  mucus  mentioned 
above.  Its  presence  in  the  eye  is  manifested  by  an  uncomfortable  feeling  of 
pressure,  similar  to  that  caused  by  a  foreign  body.  After  some  hours,  the  eschar 
is  throAvn  off,  and  then  we  see  a  somewhat  red  and  raw  mucous  membrane,  which 
secretes  a  thin  mucus.  The  raw  condition  of  the  mucous  membrane  may  pass 
away  soon,  or  persists  for  some  days  We  can  distinguish  two  differ- 
ent periods  in  the  effects  following  cauterization  of  a  healthy  eye: — 

"1.  The  period  in  which  the  eschar  first  loosens  itself  at  the  edge,  and  is  lifted 
from  the  underlying  mucous  membrane  by  a  layer  of  secretion,  and  is  then  rolled 
up  in  the  conjunctival  sac,  mostly  in  the  neighbourhood  of  the  retro- tarsal  fold, 
and  is  finally  thrown  off  in  the  form  of  a  white  secretion.  This  is  the  period  of 
irritation,  which  is  manifest  by  pain,  inability  to  open  the  eye,  laehrymation,  red- 
ness, and  more  or  less  swelling  of  the  edges  of  the  lids. 

"2.  The  period  of  regeneration,  in  which  the  conjunctiva  loses  its  raw,  red 
appearance,  through  the  reproduction  of  new  epithelium.  The  period  of  irrita- 
tion lias  now  passed  away,  and  there  only  remains  a  feeling  of  weakness  or  con- 
traction of  the  lids. 

"The  special  healing  action  of  caustics  in  inflammatory  affections  of  the  con- 
junctiva is,  above  all,  a  matter  of  experience.  We  will,  in  order  to  bring  this 
experience  under  our  control,  communicate  somewhat  in  detail  all  the  circum- 
stances in  connection  with  it.  If  a  drop  of  a  very  weak  solution  of  nitrate  of 
silver  (gr.  ss-j  to  3j)  is  put  into  an  eye  suffering  from  an  acute  conjunctivitis,  it 
causes  some  pain,  the  inflammation  is  somewhat  increased,  but  no  remission  in 
the  inflammatory  symptoms  referable  to  the  medicine  is  observed  to  follow.  Older 
authors  were  evidently  aware  of  this,  for  they  said  that  during  the  acute  stage  of 
conjunctivitis  astringents  are  not  useful,  but  are  to  be  avoided,  for  in  the  irritated 
condition  such  astringents  act  as  irritants,  increasing  the  inflammation.  When, 
under  the  same  circumstances,  we  apply  a  caustic  solution  of  the  strength  of  x  gr. 
to  ^j,  the  pain  immediately  following  the  application  is  not  proportionately  in- 
creased, but  becomes  more  prominent  at  the  period  of  the  throwing  off  of  the 
eschar,  since  at  the  beginning  the  eschar  protects  the  raw  mucous  surface.  The 
pain  reaches  its  maximum  when  the  detached  eschar  is  rolled  up  and  the  raw 
mucous  surface  is  completely  exposed;  the  redness  also  increases  very  much  at 
this  time,  as  well  as  the  other  symptoms  of  irritation,  spasm  of  the  lids,  heat,  etc. 
But,  during  the  period  of  regeneration,  we  see  not  only  this  increase  of  inflamma- 
tory symptoms  subside,  but  also  such  a  considerable  remission  as  regards  the  pre- 
vious condition,  that  after  the  lapse  of  this  period,  often  already  after  twenty-four 
hours,  the  eye  regains  almost  its  normal  appearance;  and  especially  does  this 
occur  if,  during  the  period  of  separation  of  the  eschar,  cold  fomentations  are  ap- 
plied  

"For  the  more  detailed  method  of  application  of  the  remedy  I  offer  the  fol- 
lowing points  for  consideration:  — 

"1.  The  energy  of  the  application  must  be  proportional  to  the  degree  of  in- 


220 


Bibliographical  Notices. 


[July 


jeetion  and  swelling;  otherwise  the  caustie  acts  only  as  an  irritant,  and  no  remis- 
sion follows. 

"2.  Especially  is  it  important,  if  we  wish  to  obtain  the  full  effects,  that  the 
caustic  come  in  contact  with  the  whole  of  the  conjunctival  surface.  It  is  also 
important  to  limit  the  caustic  action  to  the  various  parts  proportional  to  their 
degree  of  implication. 

"3.  If  the  intumescence  of  the  mucous  membrane  is  so  considerable  that  it 
appears  necessary  to  bring  about  a  collapse  as  soon  as  possible,  it  is  advisable  to 
scarify  at  each  cauterization. 

"4.  After  each  cauterization  cold  applications  must  be  used  until  the  eschar  is 
thrown  off". 

"  5.  The  proper  repetition  of  the  cauterization  is  of  special  importance.  When, 
after  the  reaction  following  the  cauterization  (increased  heat,  swelling,  etc.)  has 
subsided,  on  an  inspection  of  the  mucous  membrane,  the  last  eschar,  or  the  exu- 
dation accompanying  it,  is  found  to  have  been  thrown  off,  and  the  whitish  secre- 
tion following  the  cauterization  is  reduced  to  a  minimum,  and  a  collapse  has 
evidently  set  in,  but  no  sign  of  a  recrudescence  of  the  blenorrhcea  (thin  secretion, 
renewed  difficulty  in  opening  the  lid,  more  swelling  and  heat)  is  manifest,  then 
the  cauterization  may  be  repeated. 

"G.  The  presence  of  an  affection  of  the  cornea  is  supposed  to  offer  special  indi- 
cations for  the  employment  of  the  remedy.  With  a  view  of  obtaining  a  settled 
conviction  on  this  point,  I  have  instituted  an  accurate  examination  of  a  large 
number  of  cases,  and  have  arrived  at  the  following  conclusion :  that  an  already 
existing,  consecutive  corneal  affection  in  whatever  form,  whether  perforation  is 
present  or  not,  offers  no  contraindication  to  the  employment  of  caustics  in  accord- 
ance with  the  rules  laid  down  above,  but  with  proper  careful  neutralization  so 
much  the  more  urgently  demands  it. 

"  7.  That  of  all  the  caustic  means  which  are  used  in  the  treatment  of  acute 
catarrho-blennorhagic  affections,  the  nitrate  of  silver  is  the  most  reliable.  Its 
advantages  are:  1.  A  solid  eschar,  which,  with  careful  neutralization,  can  be 
limited  to  a  desired  part,  and  its  action  accurately  calculated.  2.  A  copious 
serous  secretion  at  the  commencement  of  the  period  of  detachment,  which  is 
rapidly  followed  by  a  collapse  of  the  vessels — therefore  the  most  certain  counter- 
action against  the  existing  alteration.  3^  The  possibility,  through  combination 
with  nitre,  as  well  as  through  neutralization  (with  salt  water)  of  controlling  its 
action  with  great  exactness." 

In  a  postscript  to  the  first  number  of  the  Archiv,  Grafe  gave  notice  that  in 
future  he  would  have  the  editorial  co-operation  of  Prof.  Donders  of  Utrecht, 
and  Prof.  Arlt  of  Prague. 

To  give  a  list  even  of  the  valuable  papers  that  appeared  in  the  subsequent 
numbers  of  the  Archiv,  from  the  hand  of  the  principal  editor,  would  occupy 
many  pages.  No  part  of  the  domain  of  ophthalmology  but  received  careful  con- 
sideration at  his  hands.  It  would  be  impossible,  in  a  notice  of  the  length  this 
must  necessarily  be,  to  give  a  synopsis  of  all  these  contributions  to  ocular  pa- 
thology and  practice.  The  special  student  must  search  for  these  in  the  volumes 
themselves.  We  will  select  from  them  the  articles  on  two  subjects  with  which 
his  name  will  be  most  generally  associated,  namely,  glaucoma,  and  the  extrac- 
tion of  cataract. 

Glaucoma,  or  "green  amaurosis,"  as  it  was  called,  had  been  for  all  time  the 
nolle  me  tang  ere  of  ophthalmology.  No  settled  views  were  held  either  as  re- 
gards its  pathology  or  therapeutics.  Grafe' s  studies  in  this  line,  as  was  habitual 
with  him,  were  begun  from  a  practical  standpoint.  His  great  aim  was  to  find  a 
remedy  for  a  disease  whc?e  course  had  heretofore  only  ended  in  blindness.  His 
attention  was  early  directed  to  the  prominent  and  characteristic  symptom  of  the 
affection — increased  hardness  of  the  globe ;  and  among  other  means  for  the  relief 
of  the  condition  he  tried  paracentesis  of  the  anterior  chamber.  This  was  fol- 
lowed by  marked  relief,  but  it  was  not  permanent.    If  now,  he  reasons,  we  can 


1878.]    Michaelis,  Albrecht  von  Graefe,  his  Life  and  Works.  221 


find  a  means  by  which  this  alteration  can  be  rendered  permanent,  we  shall  have 
found  the  long-sought-for  remedy.  His  previous  experience  as  to  the  effect  of 
iridectomy  led  him  to  hope  that  in  this  operation  a  means  was  at  command  for 
effecting  a  continuous  reduction  of  the  intraocular  tension.  In  1856  he  made 
the  first  operation  of  this  character,  and  in  1857  he  published  his  classical  paper 
on  the  subject  "  On  Iridectomy  in  Glaucoma  and  the  Glaucomatous  Process"  in 
the  third  volume  of  the  Archiv. 

He  was  the  first  to  introduce  the  operation  of  iridectomy  into  Germany.  He 
had  learned  its  value  from  Desmarres  in  Paris.  He  demonstrated  not  only  the 
general  innocuousness  of  the  operation,  but  pointed  out  its  great  usefulness  in 
inflammatory  affections  of  the  iris,  choroid,  and  cornea.  He  showed  conclu- 
sively that  it  was  one  of  the  most  powerful  antiphlogistics  in  the  hands  of  the 
ophthalmic  surgeon.  But,  as  is  common  with  all  valuable  discoveries,  his 
method  met  with  opposition,  and,  in  places,  of  a  violent  character — notably  in 
England.  The  great  Nestor  of  British  ophthalmology,  Bowman,  however,  came 
to  the  front,  and  soon  the  whole  world  gave  way,  and  now  the  diagnosis  of  glau- 
coma can  mean  only  the  performance  of  iridectomy.  Different  practitioners 
may  have  different  views  regarding  the  modus  operandi  of  the  procedure,  but  no 
one  doubts  its  efficacy. 

Grafe  was  the  first,  too,  to  point  out  the  true  meaning  of  the  appearance  of  the 
optic  disk  in  glaucoma  cases.  Jaeger  had  considered  the  peculiar  appearance  of 
*  the  disk  in  such  cases  as  due  to  a  bulging  of  the  end  of  the  nerve.  Grafe  at  first 
fell  into  the  error  of  so  thinking  also,  but  afterwards  convinced  himself  that  the 
displacement  of  the  vessels  was  not  forward,  but  backward — a  view  which  was 
verified  soon  after  by  H.  M tiller  on  section  of  a  glaucomatous  eye. 

The  second  great  work  of  Giiife's  life  was  the  perfection  of  the  operation  for 
extraction  of  cataract.  There  has  been  from  time  to  time  a  disposition  among 
ophthalmic  surgeons  to  try  new  methods,  and  some  oculists  of  eminence  have 
brought  forward  operations  of  their  own,  but  none  have  come  into  anything  like 
general  use.  The  majority  of  these  methods  aim  to  do  away  with  the  iridec- 
tomy, which  indeed  is  a  laudable  endeavour,  but  the  plan  yet  remains  to  be 
found  which  can  save  the  iris  and  yet  be  so  well  adapted  to  all  cases  as  they 
come  as  the  latest  improved  method  of  Grafe.  As  Grafe  himself  remarked,  his 
method  is  not  only  adapted  for  the  safe  removal  of  the  lens,  but  is  especially 
indicated  in  various  conditions,  which  are  very  frequently  found  associated  with 
cataract — such  as  an  increase  of  intraocular  tension,  affections  of  the  iris,  choroid, 
cornea,  etc.  Experience  has  shown  the  correctness  of  this  view,  for  most  of  the 
new  methods  are  recommended  by  their  authors  for  cases  of  simple,  uncompli- 
cated cataract.  Wecker  himself  now  selects  the  cases  for  his  "  peripheral  flap." 
He  only  does  it  when  the  case  is  one  of  simple  cataract  unaccompanied  by  indi- 
cations which  Grafe  had  pointed  out  as  requiring  an  iridectomy. 

Grafe  had  his  attention  first  directed  to  the  extraction  of  cataract  when  he 
went  to  Prague  to  observe  the  practice  of  Arlt,  since  in  Berlin,  at  that  time,  no 
operations  were  done  but  by  depression.  When  he  went  to  Vienna  he  saw 
Jaeger  extracting  certain  kinds  of  cataracts  by  a  linear  incision.  It  is  certain  that 
he  early  made  a  study  of  cataract  extraction,  since  in  the  second  number  of  the 
first  volume  of  the  Archiv  he  has  a  paper  on  "  Linear  Extraction  of  Cataract, 
with  Remarks  on  the  Diagnosis  of  the  Consistency  of  Cataracts,  and  on  the 
choice  of  the  various  operative  procedures."  In  this  paper  he  points  out  the 
limits  of  the  usefulness,  as  he  then  considered,  of  the  linear  method.  He  did 
not  deem  it  suitable  for  cataracts  with  hard  nuclei.  Five  years  later,  however, 
in  1859,  he  published  an  article  in  his  Archiv  on  "Two  Modifications  of  the 
Cataract  Operation."    The  two  modifications  in  question  were,  the  making  of 


222 


Bibliographical  Notices. 


[July 


an  iridectomy  and  the  removal  of  the  lens  with  a  spoon.  He  was  led  to  make 
the  iridectomy  because  he  found  otherwise  a  difficulty  in  the  introduction  of  the 
spoon,  and  as  one  of  the  most  pernicious  results  of  extraction  was  iritis,  he 
hoped,  from  his  now  extended  experience  in  iridectomies,  to  be  able  to  forestall 
such  an  untoward  event.  These  modifications  were  first  applied  to  the  linear 
incision,  which  was  made  on  the  temporal  side  of  the  eye,  but  he  afterward  ap- 
plied them  to  the  flap  method,  which  he  still  continued  to  practise. 

Gr'afe  was,  however,  not  alone  in  the  employment  of  the  spoon.  Critchett 
and  Bowman,  of  London,  both  began  about  this  time  to  use  it.  Jacobson,  of 
Konigsberg,  issued  a  pamphlet  on  "  A  Xew  and  Dangerless  Operation  for  the 
Cure  of  Cataract"  in  18G3.  This  was  dedicated  to  "his  dear  friend  and  teacher, 
A.  von  Gr'afe."  In  this  paper  Jacobson  suggests  the  peripheral  incision,  made 
upward— lying  at  its  base  at  least — in  the  corneo-scleral  junction.  He  also 
pointed  out  the  almost  absolute  necessity  of  making,  at  the  same  time  an  iridec- 
tomy, and,  in  passing,  paid  a  tribute  to  Grafe  for  his  great  work  in  demon- 
strating the  immense  value  of  iridectomy  under  such  a  variety  of  circumstances. 
Gr'afe,  in  his  turn,  gave  Jacobson  the  credit  of  introducing  the  scleral  incision. 
In  the  third  number  of  the  eleventh  volume  of  the  Archiu,  Grafe  gave  a  full 
exposition  of  the  whole  subject.  In  this  he  still  retains  the  name  of  "  modified 
linear  extraction."  In  another  article  in  the  14th  volume,  he  changes  the  name 
to  the  "peripheric  linear  extraction."  In  the  meanwhile  he  had  gradually 
abandoned  the  use  of  traction  instruments  except  in  rare  cases,  and  the  method  * 
was  now  complete  as  we  have  it  to-day.  It  will  be  seen  that  what  is  now  called 
Grate's  method  was  not  the  result  of  a  happy  accident,  but  was  of  that  slow 
growth  which  must  be  enduring.  Progress  was  made  step  by  step,  and  the 
election  from  all  the  other  plans  and  methods  was  made  with  great  caution,  and 
only  adopted  as  a  part  when  ample  experience  had  proven  their  right  to  accept- 
ance. The  ready  exit  of  the  lens,  and  the  accurate  coaptation  of  the  wound, 
were  secured  by  the  linear  incision ;  the  danger  to  sloughing  of  the  cornea  was 
avoided  by  the  peripheral  situation  of  the  wound  ;  the  danger  of  iritis  was 
lessened  by  an  iridectomy.  It  is  doubtful  whether  any  other  plan  will  ever  be 
devised  which  will  combine  all  these  advantages. 

The  temptation  is  great  to  take  up  other  subjects  on  which  Gr'afe  threw  the 
light  of  his  genius,  but  space  is  wanting,  and  enough  has  already  been  given  to 
show  that  Grafe  has  won  his  way  justly  not  only  to  the  position  of  one  of  the 
greatest  benefactors  of  his  race,  but  to  the  very  highest  rank  in  science  to  which 
a  man  may  hope  to  attain.  S.  M.  B. 


Art.  XXIV. — Lectures  on  Medical  Jurisprudence.  By  Francis  Ogstox. 
M.D.,  Professor  of  Medical  Jurisprudence  and  Medical  Logic  in  the  Univer- 
sity of  Aberdeen.  Edited  by  Francis  Ogston,  Junior,  M.U.,  Assistant  to 
the  Professor  of  Medical  Jurisprudence,  and  Lecturer  on  Practical  Toxicology 
in  the  University  of  Aberdeen.  8vo.,  pp.  xii.  663.  Philadelphia  :  Lindsay  & 
Blakiston,  1878. 

Only  a  few  months  ago  we  had  occasion  to  offer  to  the  readers  of  this  Journal1 
some  critical  observations  on  the  (then)  last  published  work  on  medical  jurispru- 
dence—  Woodman  and  Tidy's  Forensic  Medicine  and  Toxicology.  AVe  then 
expressed  the  hope  that  the  recent  rather  cumulative  publication  of  works  in  this 


1  January,  1878. 


1878.]  Ogston,  Lectures  on  Medical  Jurisprudence. 


223 


department  of  science  was  indicative  of  an  increasing  appreciation  of  the  import- 
ance of  a  knowledge  of  legal  medicine  to  both  the  physician  and  lawyer.  We  are 
now  confronted  with  yet  another  large  and  handsome  volume  upon  the  same  sub- 
ject, by  a  well-known  Scottish  authority,  and  bearing  the  American  imprint  of 
one  of  our  established  medical  publishing  houses.  We  may,  at  the  onset,  reiterate 
the  hope  before  expressed,  that  the  appearance  of  the  present  work,  like  that  of 
its  predecessor,  affords  a  healthful  indication  of  a  growing  interest  in  matters  per- 
taining to  forensic  medicine. 

The  work  of  Dr.  Ogston  comprises  forty-four  lectures  delivered  by  him  in  the 
University  of  Aberdeen.  They  were  intended,  as  the  author  informs  us  in  his 
preface,  to  supply  "  a  work  containing  the  various  forms  of  Scottish  medico-legal 
procedure,  differing  as  they  do  in  many  respects  from  those  of  England."  Ac- 
cordingly, throughout  the  volume,  just  prominence  is  given  to  Scottish  law  deci- 
sions and  practice.  We  do  not  propose  to  follow  these  lectures  in  detail,  or  to 
offer  a  critical  analysis  of  each  one,  however  replete  with  matters  of  interest  and 
importance.  We  shall  notice  only  such  portions  as  seem  especially  suggestive, 
since  there  must,  necessarily,  be  much  in  such  a  book  that  has  already  exhausted 
the  attention  of  the  reviewer. 

In  the  opening  lecture,  we  think  that  the  distinction  between  the  ordinary  and 
the  expert  witness  is  drawn  with  scarcely  sufficient  accuracy.  The  author  give  us 
some  interesting  information  in  regard  to  the  Scottish  mode  of  criminal  prosecu- 
tion, which  differs  in  certain  important  particulars  from  the  English  and  American 
practice.  In  Scotland,  the  prosecution  of  crime  is  not  left,  as  in  England  and  the 
United  States,  to  the  injured  individual  or  his  friends,  but  is  intrusted  to  a  public 
officer,  the  Lord  Advocate,  or  his  deputies  (answering  to  the  Procureur  G4n6ral 
of  France),  at  the  public  expense.  On  complaint  being  lodged  before  the  proper 
officer  of  the  borough,  county,  or  district  where  the  crime  was  committed,  the 
offending  party,  after  examination,  is  committed  to  prison  for  further  examina- 
tion. There  is  no  grand  jury,  as  with  us,  to  first  examine  into  the  merits  of  the 
case,  and  then  either  find  a  true  bill,  or  else  ignore  it  altogether  ;  but  the  whole 
evidence  is  brought  together,  reduced  to  writing,  and  then  submitted  to  the  Crown 
Counsel ;  and  it  serves  as  their  brief  on  the  trial. 

This  investigation,  or  precognition,  as  it  is  named,  determines  the  Crown  Coun- 
sel at  Edinburgh  as  to  whether  the  prisoner  shall  be  tried  or  discharged. 
Should  the  decision  be  to  go  on  with  the  prosecution,  "  the  trial  takes  place  at  the 
High  Court,  at  the  Circuit,  or  at  the  Sheriff  Court ;  and  it  is  conducted  by  the 
Lord  Advocate,  or  by  one  of  his  deputies." 

The  Scottish  mode  of  dealing  with  the  witnesses  also  differs  from  our  own  and 
the  English  :  "At  the  commencement  of  the  trial  the  witnesses  are  locked  up  in 
the  charge  of  an  officer  of  the  court,  and  are  separately  called  and  examined 
publicly  on  oath." 

By  the  Scottish  law  there  appears  to  be  absolutely  no  escape  for  a  medical 
man  being  compelled  to  act  as  an  expert  witness  for  the  precognition,  or  at  the 
subsequent  trial.  He  cannot  evade  it,  even  on  the  plea  of  ignorance  ;  the  com- 
pliment, at  least,  is  paid  him  of  supposing  him  to  be  fully  adequate  to  the  occasion 
— a  woeful  mistake,  as  is  not  unfrequently  shown.  And,  according  to  the  author, 
"a  fee  is  rarely  received  for  his  services  on  criminal  occasions."  Contrasting 
this  unfavourable  position  of  the  Scottish  medical  witness  with  that  of  the  witness 
in  the  courts  of  the  United  States,  the  author  seems  to  think  that  the  latter  has 
rather  the  worst  of  it.  He  says  of  him :  "His  attendance,  while  compulsory, 
does  not  entitle  him  in  criminal  cases  to  any  fee,  whether  cited  either  for  the 
prosecution  or  the  defence."  This  remark  requires  some  qualification.  With  us, 
no  physician  can  be  compelled  to  act  as  an  expert  witness,  if  he  asserts  his  incom- 


224 


Bibliographical  Notices. 


[July 


petence  to  give  an  opinion  touching  the  matter  at  issue.  True  it  is,  that  incompe- 
tent witnesses  do  often  thrust  themselves  forward  in  our  criminal  trials ;  but  that 
is  their  own  fault.  Again,  the  expert  witness  is  always  entitled  to  at  least  the 
fee  of  an  ordinary  witness — paltry  though  this  may  be,  together  with  mileage  ; 
and  certainly,  in  at  least  a  few  of  our  States,  he  is  allowed  an  extra  compensation 
for  his  services,  and  he  may  even  refuse  to  give  his  opinion  without  a  previous 
agreement  for  an  adequate  compensation.1  Again,  in  criminal  cases  in  the  United 
States,  and  especially  in  capital  cases,  the  defence  would  hardly  venture  to  entrust 
their  cause  in  the  hands  of  a  reluctant  expert  witness  :  and  surely  he  would  be  a 
reluctant  witness  who  had  been  dragged  away,  hundreds  of  miles  perhaps,  from 
his  home  and  business  against  his  will,  and  compelled  to  give  his  services  without 
any  adequate  compensation  ! 

The  author  gives  a  timely  caution  to  the  medical  expert  in  the  matter  of  pro- 
perly qualifying  himself  on  all  the  points  connected  with  his  testimony  ;  and  he 
very  properly  animadverts  upon  the  unprofessional  conduct  of  those  "volunteer" 
experts,  who  are  ready  on  any  occasion  to  obtrude  their  services,  and  especially 
in  capital  cases. 

The  succeeding  chapters  embrace  the  consideration  of  the  various  subjects 
usually  treated  of  in  lectures  on  medical  jurisprudence.  The  remarks  on  the 
"Determination  of  the  Age  and  Sex"  in  bodies  found  dead  cover  the  whole 
ground  relative  to  these  subjects.  The  distinctions  between  real  and  spurious 
hermaphroditism  are  carefully  drawn  and  accurately  described.  "  Personal  Iden- 
tity in  the  Living  and  the  Dead"  is  discussed  with  clearness.  The  most  import- 
ant medico-legal  point  connected  with  the  former  is  the  possibility  of  obliterating 
scars  and  tattoo  marks  from  the  body.  The  researches  of  Casper,  Tardieu  and 
others  have  settled  this  question  affirmatively,  in  quite  a  large  number  of  cases. 
Our  readers  will  readily  recall  some  remarkable  instances  of  mistaken  identity  in 
the  living,  either  from  their  reading,  or  possibly  from  their  own  personal  experi- 
ence. The  identity  of  the  dead  is  usually  determined  by  the  existence  of  certain 
well-remembered  marks,  sear?,  deformities,  or  artificial  teeth.  It  will  be  recol- 
lected by  many  that  it  was  especially  by  the  latter  circumstance  (the  artificial 
teeth),  that  the  body  of  Dr.  Parkman  was  recognized,  in  the  celebrated  Webster 
case  that  occurred  in  Boston  in  1849.  The  attempt  to  identify  the  age,  sex, 
and  height  of  the  deceased,  by  the  inspection  of  the  skeleton,  is  often  successful 
in  the  hands  of  the  expert  legal  physician. 

The  lecture  on  "Impotence  and  Sterility"  is  clear  and  comprehensive,  em- 
bracing all  that  is  known  upon  the  subject.  In  that  on  "Rape,"  the  author  is 
sufficiently  clear  and  precise  in  pointing  out  the  facility  with  which  a  perfectly 
innocent  man  may  be  made  the  dupe  of  a  designing  mother,  and  implicated  in  a 
charge  of  rape  upon  her  daughter,  when  the  latter  was  in  reality  suffering  from 
infantile  leucorrhoea  (vulvitis),  a  disorder  frequently  occurring  in  children  brought 
up  in  filth  and  poverty.  As  the  symptoms  of  this  disease  very  closely  resemble 
the  effects  of  violation  upon  a  child,  it  is  easy  to  understand  how  readily  such  a 
criminal  charge  might  be  preferred,  especially  if  there  were  favouring  circumstances. 
Several  cases  are  recorded  by  Ryan,  Beatty,  Sir  A.  Cooper,  Devergie.  and  others, 
in  which  innocent  men  narrowly  escaped  the  penalty  of  execution  on  such  a  false 
charge. 

The  question  of  the  possibility  of  unconscious  rape  upon  a  woman  under  the 
influence  of  an  anaesthetic  receives  only  a  passing  notice.  This  subject,  we  think, 
has  an  important  medico-legal  bearing  in  another  direction,  namely,  where  the 

1  Lately  so  decided  by  the  Supreme  Court  of  Indiana.  See  papers  on  Medical  Ex- 
pert Evidence  in  Phila.  Med.  and  Surg.  Reporter,  vol.  xxxviii.  Xos.  16  and  18. 


1878.] 


O G s t on ,  Lectures  on  Medical  Jurisprudence. 


225 


charge  is  falsely  made  against  an  innocent  man  by  a  female  who.  while  anaesthe- 
tized by  ether  or  chloroform,  may  have  experienced  an  erotic  dream  suggestive 
of  the  act  imputed.  It  is  well  known  that  such  is  one  of  the  effects  of  these  anaes- 
thetics on  women  :  the  patients  themselves  have  confessed  it.  AYe  need  scarcely 
advert  to  the  absurdity  of  admitting  any  such  evidence  on  the  part  of  the  prose- 
cutrix, unsup>ported  by  a  careful  medical  examination  ;  and  yet,  as  will  doubtless 
be  remembered  by  some  of  our  readers,  this  very  absurdity  was  committed  in  our 
own  city,  some  twenty  years  ago,  in  a  trial  in  which  a  highly  respectable  dentist 
Avas  convicted  of  such  a  felonious  attempt,  simply  on  the  testimony  of  a  female 
patient  to  whom  he  had  administered  ether  before  extracting  or  filling  a  tooth. 

The  jurisprudence  of  obstetrics  is  embraced  in  four  lectures,  comprising  the  sub- 
jects of  •  •  The  Signs  of  Pregnancy  ;"  ' k  Proofs  of  Delivery,  Recent  and  Remote 
"  Unconscious  Delivery ;"  "Protracted  Gestation,  as  affecting  the  Question  of 
Legitimacy;"  "Live  Birth;"  and  "  Criminal  Abortion."  In  reference  to  the 
subject  of  live  birth  in  connection  with  that  of  tenancy  by  the  courtesy  (by  virtue 
of  which  the  husband  of  a  deceased  wife  is  entitled  to  a  life-interest  in  her  estate, 
provided  she  has  live  issue),  it  should  be  remembered  that  the  law  of  Scotland 
differs  from  that  of  England  and  America  as  regards  the  test  of  a  live  birth.  In 
the  former,  it  is  the  establishment  of  respiration  ;  by  the  latter,  a  child  may  acquire 
its  civil  rights,  although  it  may  be  neither  seen  to  breathe  nor  heard  to  cry,  pro- 
vided it  exhibits  other  signs  of  life,  such  as  pulsations  of  the  heart  or  arteries,  or 
even  the  spasmodic  twitching  of  any  of  the  muscles  of  the  body.  The  Scottisli 
law  on  this  subject  presents  us  with  this  singular  anomaly,  that  while  it  requires 
proof  of  respiration  or  crying  as  evidence  of  a  live  birth,  it  does  not  recognize  that 
the  child  is  "born"  unless  it  is  completely  separated  from  its  mother;  even 
although  it  may  have  cried  lustily,  with  its  head  and  shoulders  extruded,  but  its 
feet  still  retained  ! 

The  lectures  on  "  Criminal  Abortion"  and  "  Infanticide"  convey  a  correct  and 
sufficiently  copious  description  of  these  subjects.  Under  Infanticide,  the  author 
reiterates  the  common  observation  concerning  the  difficulty  of  procuring  a  verdict 
against  the  woman,  even  in  the  face  of  the  most  direct  evidence.  Undoubtedly, 
this  reluctance  on  the  part  of  the  jury  to  convict  arises  from  a  false  sympathy  with 
the  unhappy  culprit,  which  the  stern  demands  of  justice  should  disregard.  But 
there  will  be  always  more  or  less  of  this  sympathy  in  the  community,  as  well  as 
in  the  jury-box,  when  the  punishment  of  the  prisoner  is  contrasted  with  the  im- 
munity too  generally  accorded  to  the  other  party.  Probably,  as  the  author  sug- 
gests, "  the  best  means  to  secure  the  certainty  of  punishment  for  the  commission 
of  this  crime  would  be  to  lessen  the  severity  of  the  penal  enactments."  As  the 
law  at  present  stands,  infanticide  is  regarded,  like  any  other  homicide,  as  a  capital 
crime,  although  the  prosecution  is  always  bound  first  to  prove  the  live  birth  of  the 
child.  Nor  must  it  be  forgotten  that,  by  a  singular  freak  of  the  law,  it  is  not 
child-murder,  technically  speaking,  to  take  away  its  life,  if  only  its  head  and  body 
be  born  ! 

As  an  evidence  of  previous  live  birth,  the  hydrostatic  test  receives  a  thorough 
examination.  It  must  not  be  forgotten  that  this  so-called  test  is  never  to  be  re- 
garded as  the  true  criterion  of  a  live  birth  ;  it  is  merely  the  evidence  of  respira- 
tion, or  rather  of  an  inflation  of  the  lungs,  either  naturally  or  artificially.  We 
should  not  lose  sight  of  the  fact  that  a  child  may  be  born,  and  live  some  time, 
and  die,  without  respiration.  Here,  of  course,  the  hydrostatic  test  would  be 
entirely  at  fault.  Moreover,  it  would  equally  fail,  on  the  other  hand,  in  those 
cases  where  the  child,  when  partially  born  (or  even  before  its  birth,  when  there 
is  the  vagitus  uterinus),  both  breathes  and  cries,  but  dies  before  the  birth  is  com- 
pleted. 

No.  CLI  July  1878.  15 


226 


Bibliographical  Notices. 


[July 


Four  lectures  are  devoted  to  the  consideration  of  the  important  subject  of  "  In- 
sanity" in  its  medico-legal  bearings, — a  field  entirely  too  extensive  for  us  to  enter 
upon  in  the  present  article.  The  author  discusses  the  subject  with  sufficient  pre- 
cision. He  adopts  the  classification  of  Dr.  Hay,  with  some  modifications.  The 
questions  of  Civil  and  Criminal  Responsibility  are  treated  with  candour  and 
ability.  The  subject  of  the  plea  of  insanity  as  a  bar  to  judicial  punishment  is 
fully  discussed  and  criticized.  In  monomania,  the  doctrine  is  laid  down  that  this 
does  not  disqualify  the  subject  from  "  attending  to  his  own  affairs."  Very  little 
is  said  upon  the  subject  of  suicide  as  an  evidence  of  insanity.  Whilst  many  per- 
sons are  disposed  to  regard  suicide  as  unmistakable  evidence  of  insanity,  we  think 
that  there  are  unquestionable  instances  where  this  plea  cannot  be  admitted,  but 
where,  on  the  contrary,  a  sufficiently  coherent  and  cogent  motive  may  be  shown 
for  its  commission. 

The  chapters  on  "  Death  in  its  Medico-Legal  Aspects"  are  among  the  most  in- 
teresting and  instructive  in  the  book.  Several  points  might  be  examined  in 
extenso,  did  space  permit ;  we  will  only  mention  apparent  death,  cadaveric  spasm, 
and  cadaveric  lividities  (external  hypostases)  as  distinguished  from  ecchymoses. 
The  formation  of  adipocere  receives  too  hasty  a  notice,  considering  its  occasional 
importance  as  a  factor  in  determining  the  date  of  death. 

The  lectures  on  "Wounds"  require  no  special  notice  from  us,  except  in  the 
matter  of  blood-stains,  in  which  we  think  the  author  has  not  displayed  his  usual 
precision,  either  as  regards  the  guaiacum-test,  or  the  possibility  of  discrimination, 
by  means  of  the  microscope,  between  the  blood-corpuscles  of  man  and  those  of 
the  more  familiar  domestic  animals  (the  dog  and  rabbit  excepted).  He  seems 
disposed  even  to  question  the  ability  of  the  accomplished  microscopist  to  deter- 
mine the  differences  in  their  size.  Surely,  he  could  hardly  have  read  the  papers 
of  our  townsman,  Prof.  J.  G.  Richardson,  which  demonstrate  most  satisfactorily, 
we  think,  the  ability  to  make  this  diagnosis,  provided  a  very  high  power  is  used. 

In  the  chapter  on  "  Death  by  Hanging,"  no  mention  is  made,  among  the  signs 
of  this  mode  of  death,  of  fracture  of  the  crystalline  lens.  This  sign,  we  believe, 
was  first  pointed  out  by  Dr.  Dyer  in  the  year  I860,  as  witnessed  by  himself,  in 
the  eyes  of  an  executed  criminal,  and  also  in  the  eyes  of  two  dogs  subsequently 
killed  by  hanging.  Quite  recently,  these  experiments  were  repeated  by  Dr.  Ar- 
thur G.  Allan,  of  this  city,  who  made  them  the  -subject  of  his  prize  essay.  Seven 
dogs  were  hanged  ;  and  in  every  instance,  on  examination  after  death — the  proper 
care  having  been  taken  as  regards  the  fall,  etc. — there  was  an  entire  absence  of 
the  line  indicating  a  fracture  of  the  lens.  Consequently,  we  must  regard  this 
alleged  sign  of  death  by  hanging  as  not  sustained  by  experiment. 

In  the  lecture  on  "Death  by  Heat,"  allusion  is  made  to  the  occasional  preter- 
natural combustibility  of  human  bodies ;  but  the  author,  very  properly,  we  think, 
does  not  advocate  the  doctrine  of  the  spontaneous  combustion  of  the  human 
body. 

The  subject  of  "Toxicology,"  although  confessedly  one  of  the  most  important 
to  the  legal  physician,  receives  only  a  general  notice  from  our  author.  The 
editor  explains  in  the  preface  his  omission  of  Special  Toxicology  from  the  work. 
4 '  as  this  subject  has  been  so  often  and  so  ably  treated  of  in  books  devoted  to 
that  department  of  legal  medicine."  The  four  lectures  devoted  to  General  Tox- 
icology contain  many  admirable  hints  to  the  practitioner,  and  the  whole  subject 
is  handled  with  skill  and  precision.  It  is  hardly  necessary  to  particularize. 
Some  timely  warnings  are  given  as  to  the  impropriety  of  always  drawing  in- 
ferences from  experiments  on  the  lower  animals  with  poisons,  as  to  their  effects 
on  man,  since  it  is  well  known  that  some  of  the  inferior  animals  are  not  at  all 
affected  by  articles  which  are  fatally  poisonous  to  the  human  subject — such  as 
opium,  hyoscyamus,  belladonna,  etc. 


1878.] 


F  i  all  a,  Cure  of  Congenital  Cataract. 


227 


The  possibility  of  introducing  a  poison  into  the  body  after  death,  with  a  view 
of  imputing  the  crimes  of  poisoning  to  an  innocent  person,  is  very  briefly  allnded 
to.  This  is  a  subject  of  very  considerable  medico-legal  importance,  inasmuch  as 
it  has  been  shown1  that  in  this  way  the  liver  and  other  viscera  of  the  body  may 
become  contaminated  through  osmosis  of  the  poison  from  the  stomach,  and  may 
thus  exhibit,  apparently,  the  very  best  evidence  of  an  ante-mortem  poisoning.  Such 
a  serious  mistake  would  probably  be  best  avoided  by  an  examination  of  the  brain 
and  spinal  cord  for  the  alleged  poison  ;  since  it  has  been  shown  by  M.  ScolosubofF2 
that  arsenic  (and  inferentially  all  the  mineral  poisons),  when  taken  as  a  poison, 
is  always  found  after  death  in  large  quantities  in  the  brain  and  spinal  marrow. 
In  a  case  of  the  post-mortem  imbibition  of  a  poison,  it  is  not  possible  that  the  lat- 
ter could  penetrate  from  the  stomach  to  the  contents  of  the  cranium  or  the  spinal 
column. 

From  our  preceding  remarks  it  will  be  gathered  that  we  have  a  high  appre- 
ciation of  Prof.  Ogston's  lectures,  and  can  cordially  recommend  the  work  as  ac- 
complishing all  that  the  distinguished  author  promised  for  it.  The  few  wood-cuts 
which  accompany  the  letter-press  are  by  no  means  on  a  par  with  the  rest  of  the 
volume,  which  is  beautifully  gotten  up,  and  bears  the  Edinburgh  imprint. 

J.  J.  R. 


Art.  XXV. —  Gue'rison  de  Six  Aveugles-nes.  Par  M.  le  Dr.  Louis  Fialla, 
Chef  du  Service  Chirurgical  a  l'Hopital  Philanthropic.  8vo.,  pp.  32.  Bucarest, 
Thiel  &  Weiss,  1878. 

These  cases  all  occurred  in  the  author's  practice  in  two  years.  Certainly  a 
very  unusual  experience,  though  the  statement  that  but  14  cases  of  congenital 
cataract  have  been  reported  in  149  years  would  not  give  a  correct  idea  of  its 
frequency.  This  estimate  may  not  be  so  very  far  wrong,  however,  if  confined 
to  the  kind  of  cases  appropriate  for  observations  such  as  the  author  has  made. 
These  require  a  successful  operation  in  a  person  who  is  of  sufficient  age  to  give 
an  intelligent  account  of  his  impressions,  and  who  has  been  entirely  blind  before 
the  operation.  In  a  large  proportion  of  cases  the  operation  is  performed  in  early 
childhood,  in  many  the  patients  have  had  more  or  less  vision,  enough  to  guide 
them  partially,  before  the  operation,  and  in  some,  it  must  be  confessed,  they  have 
not  very  much  after  it ;  not  only  because  the  operation  for  congenital  cataract, 
like  all  other  operations,  is  subject  to  mishaps,  but  because  even  after  the  most 
perfect  operation  the  eye  is  often  found  otherwise  impaired  or  imperfectly 
developed. 

Dr.  Fialla  attributes  the  unusual  number  of  his  cases  to  a  want  of  confidence 
in  the  art  of  medicine  among  the  lower  classes  in  Roumania,  which  prevented 
them  from  applying  earlier  for  aid.  One  of  them  had  vision  enough  before  the 
operation  to  render  his  case  of  little  interest;  the  rest  were  excellent  cases  for 
observation.  The  oldest  was  25  years  of  age,  and  the  youngest  7  ;  the  average 
age  being  15. 

All  the  operations  were  by  discission,  the  lenses  being  freely  lacerated  at  one 
sitting,  and,  though  in  several  cases  there  was  violent  reaction,  all  seemed  to  have 
done  well  in  the  end. 


1  Trans.  Col.  of  Physicians  of  Philadelphia,  Nov.  1876,  and  number  of  this  Journal 
for  Jan.  1878,  p.  284. 

2  Archives  de  Physiologie,  No.  5,  Aout  et  Septembre,  1875. 


228 


Bibliographical  Notices. 


[July 


The  author's  observations  upon  these  patients,  when  they  commenced  to  use 
their  eyes,  fully  confirm  the  generally  accepted  views.  He  discovered  in  none  of 
them  any  "  innate  ideas."  None  showed  any  indication  of  an  instinctive  use  of 
their  new-found  sense  ;  all  had  to  learn  to  see.  None  could  distinguish  form  or 
distance,  or  showed  at  first  the  slightest  recognition  by  sight  alone  even  of  objects 
that  had  been  familiar  to  touch  for  years.  Like  the  famous  Caspar  Hauser,  some 
found  their  first  experiences  painful  rather  than  pleasant ;  and  one  who  had 
earned  his  living  as  a  street  musician,  and  had  gone  about  the  town  alone  for 
years,  lost  himself  when  his  eyes  were  opened,  and  had  to  beg  some  one  to  lead 
him  home. 

Three  of  the  patients  had  nystagmus,  and  none  of  them  had  perfect  control  of 
the  external  muscles  when  they  commenced  to  use  their  eyes.  Sometimes  a 
temporary  strabismus  was  noticed  when  the  attempt  was  made  to  fix  an  object. 
They  soon  learned,  however,  to  direct  the  visual  axis  properly,  and  in  only  one 
case  did  any  difficulty  of  this  kind  remain  when  the  patient  left  the  hospital.  A 
similar  disappearance  of  nystagmus  after  the  restoration,  or  rather  acquisition,  of 
sight,  is  noted  in  an  interesting  case  of  congenital  cataract  cured  by  operation, 
reported  by  Dr.  Wm.  Hunt  in  the  Phila.  Med.  Times  for  June  16,  1875.  This 
result  shows  how  much  the  delicate  equilibrium  established  among  the  external 
muscles  of  the  balls  in  perfect  binocular  vision  may  depend  upon  practice,  and 
is  encouraging  to  our  therapeutic  efforts  in  this  direction  in  cases  in  which  this 
equilibrium  has  been  disturbed.  The  nystagmus  which  is  frequently  found  in 
miners  avIio  pass  their  lives  in  subterraneous  darkness,  and  which  has  attracted 
much  attention  lately,  is  interesting  in  this  connection. 

The  author  calls  attention  to  the  fact  that  the  favourable  issue  in  the  case  of 
the  man  25  years  of  age  shows  that  the  diffused  light  admitted  through  a  cata- 
ractous  lens  is  sufficient  to  maintain  indefinitely  the  sensitiveness  of  the  retina. 
This  passive  suppression  of  vision  is  much  less  injurious  to  the  sensitiveness  of 
the  retina  (if  indeed  it  is  at  all  so)  than  the  suppression  of  images  formed  upon 
it,  but  disregarded  by  the  sensorium  in  the  interest  of  binocular  vision,  as  in  the 
case  of  strabismus,  partial  opacities  of  the  cornea,  or  some  cases  of  difference  in 
the  refraction  of  the  eyes.  This  tact  is  fatal  to  the  argument  sometimes  used  in 
favour  of  operating  on  monocular  cataract  to  preserve  the  sensitiveness  of  the 
retina. 

Observations  like  the  foregoing  seem  to  point  to  touch  as  the  sense  by  which 
chiefly  we  discern  the  true  state  of  our  relations  with  the  world  about  us.  But, 
as  the  author  says,  all  knowledge  is  from  experience — "  connaitre  demande  une 
habitude  anterieure ;"  and  all  the  senses  stand  alike  in  need  of  exercise  and  edu- 
cation. The  question  naturally  suggests  itself,  what  kind  of  notions  of  things 
would  a  person  have  who  had  acquired  them  entirely  from  perfect  vision  without 
the  aid  of  touch  ? 

The  perception  of  colours  by  persons  who  have  newly  acquired  the  sense  of 
sight  is  a  subject  of  great  interest  and  some  difficulty,  and  we  cannot  help  sus- 
pecting that  the  views  the  author  has  adopted  in  reference  to  it  may  be  the  re- 
sult of  errors  of  observation.  Of  the  first  patient,  a  peasant  girl  17  years  of  age, 
he  says  :  "  As  to  colours,  she  rapidly  learned  to  distinguish  black  and  white  ;  then 
red  and  green.  She  hesitated  over  orange,  yellow,  and  especially  over  the 
colours  which  are  the  result  of  mingling.  The  retina  perceived  the  undulations 
of  light,  but  needed  education,  which,  no  doubt,  in  time  will  be  completed." 

The  second  case  recognized  very  easily  black,  white,  and  red,  and  with  greater 
difficulty  green,  but  none  of  the  other  colours.  It  is  added  that  "it  is  possible 
that  by  exercise  the  faculty  of  recognizing  colours  will  be  perfected."  The  third 
patient  added  yellow  to  the  list ;  of  the  other  colours  he  said  this  verges  on  red, 


1878.] 


F  i  all  a,  Cure  of  Congenital  Cataract. 


229 


or  green,  or  yellow.  The  fourth  had  vision  enough  before  the  operation  to'  gain 
some  idea  of  colour.  The  fifth,  a  bright  boy  of  seven  years,  could  not  name  the 
colours,  but  showed  his  perception  of  them  by  saying  that  a  white  coat  was  of  the 
same  colour  as  a  shirt,  and  that  red  objects  were  of  the  colour  of  fire. 

The  author  attributes  the  imperfection  of  colour  vision  in  these  cases  to  an  im- 
perfection in  the  development  of  the  retina,  and  is  convinced  that,  after  a  time, 
vision  will  be  perfected  in  this  respect  as  in  others.  If  these  observations  may 
be  considered  as  reliable,  it  is  interesting  to  note  that  in  no  case  were  the  more 
highly  refractive  colours  at  the  violet  end  of  the  spectrum  recognized. 

It  is  not  stated  what  tests  were  applied,  but  there  is  reason  to  believe  that  the 
ability  to  name  a  colour  was  confounded  with  the  physiological  perception  of  it, 
and  that  the  practice  spoken  of  was  rather  an  effort  of  the  memory  than  a  train- 
ing of  the  chromatic  sense. 

As  has  been  pointed  out  by  Helmholtz  and  others,  the  names  of  colours  have 
no  meaning  for  the  colour  blind,  much  less  for  those  who  have  had  no  vision  at 
all,  and  the  wonder  is  not  that  such  persons  find  it  difficult  to  learn  the  proper 
applications  of  these  names,  but  that  they  are  so  soon  enabled  to  make  reason- 
ably good  guesses. 

The  simplest,  and  at  the  same  time  the  best,  means  of  testing  the  colour  sense 
is  that  by  comparison.  Patients  are  directed  to  match  strands  of  coloured 
worsted.  This  plan  has  been  extensively  adopted  in  Europe,  and  attention  has 
been  particularly  called  to  it  in  this  country  by  Dr.  B.  Joy  Jeffries,  of  Boston. 

In  the  report  of  the  case  by  Dr.  Hunt,  it  is  said  "  of  colour,  of  course,  he  had  no 
idea."  Certainly  not  of  the  name  of  any  colour,  but  if  when  he  commenced  to 
see  he  was  entirely  destitute  of  the  chromatic  sense,  though  he  afterwards  could  dis- 
tinguish colours  perfectly,  the  fact  has  an  important  significance.  According  to  the 
Young-Helmholtz  theory,  which  is  pretty  generally  accepted  as  the  best  that 
can  be  done  in  that  direction  for  the  present,  there  are  retinal  elements  for  each  of 
the  three  primary  colours.  If  this  is  correct,  it  should  be  as  natural  to  perceive 
these  colours,  at  least,  as  to  distinguish  between  black  and  white.  At  any  rate  it 
is  not  a  complicated  process  requiring  the  aid  of  reason,  and  differs  in  that  respect 
from  recognizing  the  difference  between  a  flat  surface  and  a  solid,  or  between  a 
sphere  and  a  cube. 

The  retina  can  be  educated  to  nice  distinction  of  delicate  shades  of  colouring, 
but  though  the  ability  to  perceive  a  primary  colour  may  be  improved  it  cannot  be 
created,  and  it  is  almost  universally  admitted  that  a  person  once  colour  blind, 
except  from  disease,  is  always  colour  blind.  Dr.  B.J.J  effries  has  recently  written 
an  interesting  paper  on  the  incurability  of  congenital  colour  blindness.  Several 
French  writers  have,  however,  adopted  different  views.  One  of  them,  Delboeuf, 
maintains  that  Daltonism  is  not,  according  to  the  Young-Helmholtz  theory,  due 
to  an  atrophy  of  the  red  perceiving  elements,  but  to  a  preponderating  suscepti- 
bility to  green  and  violet,  and  claims  to  have  accomplished  a  partial  cure  in  his 
own  case  by  the  use  of  a  transparent  reddish  medium  to  subdue  the  green  and 
violet  rays,  and  "  establish  the  equilibrium."  He  is  hopeful  of  still  further  pro- 
gress, as  he  thinks  it  is  probably  an  affair  of  time  and  practice. 

Hugo  Magnus,  of  Breslau,  has  expanded  this  idea  of  time  and  practice  into  a 
learned  and  ingenious  argument  for  the  evolution  of  the  colour  sense.  His  con- 
clusions are  that  "  in  the  primitive  period  man  possessed  only  the  sense  of  light, 
that  of  colour  being  entirely  absent.  The  sense  of  colour  was  produced  by  gradual 
development  from  that  of  light ;  colours  were  perceived  sooner  in  proportion  to 
their  luminous  intensity :  thus,  in  the  order  of  time,  red  was  the  first  colour,  and 
violet  the  last  recognized  and  characterized  as  such.    And  it  is  not  impossible  that 


230 


Bibliographical  Notices. 


[July 


our  descendants  may  acquire  the  perception  of  colours  which  still  escape  the  pre- 
sent generation." 

Lastly,  Mr.  Gladstone,  stimulated  by  the  writings  of  Magnus,  and  "forgetting, 
for  the  moment,  Turks,  Russians,  and  Bulgarians,"  has  published  an  article  in  the 
Nineteenth  Century  fully  adopting  these  views,  and  he  brought  the  force  of  his  great 
classical  learning  to  prove  that  the  Homeric  age  had  not  advanced  much  beyond 
the  red  and  yellow  stage  of  chromatic  evolution. 

We  have  seen  only  an  abstract  of  Magnus's  work,  and  have  not  learned  how  he 
disposes  of  an  obvious  difficulty  in  the  fact  that  some  of  the  lower  animals  are  un- 
doubtedly possessed  of  a  more  or  less  developed  colour  sense.  G.  C.  H. 


Art.  XXVI. — Illustrations  of  Clinical  Surgery.  By  Jonathan  Hutch- 
inson, F. B.C. S.,  etc.  Fasciculi  IX.  and  X.  Folio,  pp.  193-244.  Philadel- 
phia: Lindsay  &  Blakiston,  1878. 

These  two  parts  complete  Mr.  Hutchinson's  first  volume,  and  in  giving  an 
analysis  of  their  contents,  we  finish  a  pretty  full  review  of  the  additions  this  book 
has  made  to  surgical  literature.  The  reputation  of  the  senior  surgeon  to  the 
London  Hospital  is  too  firmly  established  to  depend  altogether  upon  the  recep- 
tion which  this,  his  latest  work,  will  receive  at  the  hands  of  the  profession.  We 
therefore,  acknowledging  the  work  of  a  masterly  hand  in  its  construction,  would 
simply  call  the  attention  of  the  reader  to  the  contents  of  the  book. 

Plate  XXXII.  comprises  three  figures.  The  first  and  third  represent  instances 
of  extensive  depressed  fractures  which  occurred  some  years  ago,  and  resulted 
fatally.  Mr.  Hutchinson  thinks  that  the  injury  to  the  cerebral  substance  was 
too  extensive  to  admit  of  much  hope  from  the  use  of  the  trephine,  yet  regrets 
that  a  resort  was  not  had  to  it,  as  affording  the  only  chance  of  recovery.  In  this 
retrospective  prognosis  (if  the  bull  may  be  permitted),  he  clearly  indicates  the 
tendency  existing  among  surgeons  to  reconsider  their  attitude  of  opposition  to  the 
operation  of  trephining,  which  came  in  a  few  years  since,  and  their  present  incli- 
nation to  adopt,  in  a  modified  degree,  the  practice  of  the  surgeons  of  a  century  ago. 

Figure  2  is  of  much  interest,  representing  as  it  does  a  linear  fracture  which 
ultimately  led  to  diffuse  meningitis  with  its  attendant  symptoms.  Here  the 
trephine  was  used  late  in  the  case ;  but,  as  is  most  commonly  the  case,  the  mat- 
ter being  not  confined,  no  relief  was  afforded  by  the  step.  The  case  is  a  good 
illustration  of  the  progressive  infiltration  of  bone  which  so  often  follows  upon 
injury  of  its  structure.  It  occurred  out  of  the  wards  of  a  hospital,  and  therefore 
goes  to  show  that  such  results  cannot  justly  be  limited  to  the  effects  of  hos- 
pitalism. 

Plate  XXXIII.  consists  of  two  illustrations  of  post-mortem  perforations  of  the 
skull. 

Plate  XXXIY.  represents  the  appearance  of  the  eye  in  vaso-motor  paralysis, 
and  the  difference  between  the  paralyzed  pupil  when  seen  in  shadow  and  when 
brightly  illuminated.  The  letterpress  accompanying  the  illustrations  contains  a 
full  account  of  two  case  observed  by  Mr.  Hutchinson,  in  which  the  cervical 
sympathetic  was  injured.  The  plates  are  accurately  executed,  but  beyond  the 
very  evident  paralysis  of  the  pupil  of  the  wounded  side,  it  requires  a  close 
examination  to  distinguish  between  the  sound  and  injured  one.    It  is  impossible 


1878.]       Hutchinson,  Illustrations  of  Clinical  Surgery. 


231 


to  enter  into  this  somewhat  intricate  subject  in  this  place,  and  we  must  refer 
those  of  our  readers  who  are  interested  in  it  to  the  work  itself. 

Plate  XXX Y.  carries  us  back  to  compression  of  the  brain,  and  furnishes  a 
most  remarkable  illustration  of  a  pure  and  uncomplicated  case  of  that  injury, 
which  went  on  to  a  fatal  issue,  unsuspected,  and  therefore  without  any  attempt  at 
its  relief.  The  case  was  one  of  long  standing  caries  of  the  cranium,  without 
syphilitic  history.  A  sinus  discharging  greenish  pus  led  down  to  the  bone  im- 
mediately over  the  sagittal  suture,  and  violent  headache  was  a  constant  symptom. 
Without  any  paralysis  the  patient  gradually  became  unconscious,  and  after  one 
or  two  convulsive  seizures  died,  apparently  from  exhaustion.  Upon  examina- 
tion, between  the  calvarium  and  dura  mater,  there  were  found  from  six  to  eight 
ounces  of  pus.  There  was  no  meningitis,  the  arachnoid  being  unclouded,  and 
the  convolutions  of  the  brain  looked  as  if  they  had  simply  been  pushed  down  and 
compressed  by  the  fist.  None  of  the  symptoms  commonly  described  as  accom- 
panying compression,  such  as  laboured  pulse,  stertorous  respiration,  and  stupor, 
were  present,  and  the  case  goes  far  to  prove  how  great  an  amount  of  mechanical 
compression  can  be  endured  by  the  brain,  especially  if  the  compression  is  gradu- 
ally developed.  Mr.  Hutchinson  thinks  the  persistent  headache  can  be  best 
accounted  for  by  the  gradual  separation  of  the  dura  mater  from  its  overlying 
bone.  He  also  thinks  that  the  case  confirms  the  view  that  hemiplegia  is  rarely, 
if  ever,  an  attendant  upon  pure  compression  of  the  brain,  and  that,  if  we  only 
diagnose  that  condition  to  exist  when  the  generally  described  symptoms  are  pre- 
sent, we  shall  fail  to  recognize  many  cases. 

Passing  on  to  the  next  fasciculus,  we  find  in  Plates  XXXVI.  and  XXXVII. 
illustrations  of  phlebitis  and  pyaemia,  and  osteitis  and  pyaemia.  While  these  are 
not  new  they  are  interesting,  and  show  as  well  the  nature  of  the  complications 
which  recent  researches  have  proved  to  be  causes  of  pyaemia,  as  the  results  which 
we  now  know  have  their  origin  in  those  causes.  In  the  remarks  which  accom- 
pany these  plates,  Mr.  Hutchinson  goes  into  a  discussion  of  the  theories  of  pyaemia 
held  by  different  authorities,  and  announces  his  unfaltering  adherence  to  the 
theory  which  recognizes  phlebitis,  with  its  accompanying  obstructions,  as  the 
principal  cause  of  pyaemia. 

The  remaining  two  plates  are  uncoloured  lithographs,  representing  bullet  per- 
forations of  the  skull,  some  received  during  life,  others  inflicted  after  death. 

An  appendix,  giving  further  details  of  some  of  the  cases  pictured  in  the  book, 
and  defending  in  at  least  one  case  the  originality  of  the  author's  observation, 
completes  this  beautiful  volume. 

The  opinion  of  the  reviewer  has  been  fully  expressed  in  the  successive  notices 
by  which  he  has  sought  to  make  this  volume  known  to  the  profession.  It  is 
enough  now  to  say  that  the  anticipations  awakened  by  the  first  fasciculus  have 
been  fully  realized,  and  that  each  succeeding  part  has  only  confirmed  the  impres- 
sion that  Mr.  Hutchinson's  work  was  destined  to  take  a  high  place  among  recent 
contributions  to  surgical  literature. 

It  is  pleasant  to  know  that  the  demand  for  this  necessarily  expensive  publica- 
tion has  so  far  exceeded  the  expectations  of  its  author,  that  he  is  sufficiently  en- 
couraged to  promise  its  continuance  in  a  second  volume.  S.  A. 


232 


Bibliographical  Notices. 


[July 


Art.  XXVII.—  Atlas  of  Skin  Diseases.  By  Louis  A.  Duhring,  M.D.,  Pro- 
fessor of  Skin  Diseases  in  the  Hospital  of  the  University  of  Pennsylvania, 
Physician  to  the  Dispensary  for  Skin  Diseases,  Philadelphia,  etc.  Part  III. 
Philadelphia:  J.  B.  Lippincott  &  Co.,  1878. 

This  part  of  the  Atlas  more  than  sustains  the  high  reputation  so  deservedly 
established  by  the  preceding  numbers.  The  artist's  work  has  even  gained  in  re- 
finement of  colouring  and  delicacy  of  drawing,  so  that  it  would  be  hard  to  say  in 
what  respect  it  could  be  improved.  Indeed,  it  may  be  stated  without  boasting 
that  no  plates  recently  published  anywhere  of  similar  character  equal  these  in 
excellence  at  all  points.  Such  perfection  has  only  been  attained,  of  course,  by 
the  constant  supervision  of  the  author  at  every  stage,  and  but  few  can  appreciate 
the  time  which  he  has  bestowed  upon  this  part  of  the  work. 

The  selection  of  cases  for  illustration,  as  before,  has  been  judicious,  so  that 
characteristic  types  of  well-marked  phases  of  the  most  important  affections  have 
been  presented.  They  are  eczema  (squamosum),  purpura,  syphiloderma  (ery- 
thematosum),  and  syphiloderma  (papulosum  et  pustulosum).  The  text,  which 
accompanies  each  of  the  plates,  contains  a  short  clinical  history  of  the  case  repre- 
sented, a  description  of  the  appearances  at  the  time  its  portrait  was  painted,  con- 
cise remarks  upon  the  etiology  of  the  affection  and  its  relations  to  other  stages  and 
vai'ieties  of  the  disease,  important  instruction  concerning  points  of  differential  diag- 
nosis, and  directions  for  the  treatment  of  similar  cases.  To  those  familiar  with 
the  admirable  text-book  of  Dr.  Duhring  it  may  be  unnecessary  to  speak  of  the 
practical  character  of  the  teaching  thus  furnished ;  it  forms  no  small  part  of  the 
great  value  of  the  work.  As  the  lithographic  drawings  will  be  destroyed  after  the 
printing  of  the  present  limited  edition,  we  would  advise  our  readers  not  to  neglect 
such  an  opportunity  of  obtaining  illustrations  of  skin  diseases  as  will  scarcely 
occur  again.  J.  C.  AY. 


Art.  XXYIII. — Injuries  of  the  Eye,  and  their  Medico-Legal  Aspect.  By  Fer- 
dinand von  Arlt,  M.D.,  Professor  of  Ophthalmology  in  the  University  of 
Vienna,  Austria.  Translated,  with  the  permission  of  the  Author,  by  Chas. 
S.  Turnbull,  M.D.,  Surgeon  to  Eye  and  Ear  Department,  Howard  Hospital, 
etc.    12mo.  pp.  198.    Philadelphia:  Claxton,  Renisen  &  Haffelfinger,  1878. 

Anything  from  the  pen  of  Professor  von  Arlt  comes  to  us  stamped  with  the 
seal  of  authority,  and  therefore  the  first  appearance  of  these  papers  in  the  Wiener 
Medicinische  Wochenschrift  met  with  a  ready  acceptance  from  all  classes  of 
medical  men.  It  is  true  that  to  the  ophthalmologist  there  is  little  new  in  the 
book,  but  its  publication  puts  into  the  hand  of  the  general  practitioner  a  valuable 
little  work,  by  an  acknowledged  expert,  upon  a  subject  of  which  he  himself  is 
either  comparatively  or  entirely  ignorant.  Monographs,  in  book  form,  upon  in- 
juries of  the  eye  are  very  few  in  number,  the  most  important  being  those  of 
W.  Cooper,  and  Zander  and  Geissler,  and  one  by  Lawson,  treating  more  espe- 
cially of  railroad  injuries.  The  two  former  are  antiquated,  and  the  third  is 
limited  in  scope,  and  not  very  recent.  Hence  this  little  book  of  Von  Arlt, 
though  consisting  of  only  two  hundred  pages,  fills  a  space  that  was  empty,  par- 
ticularly on  the  medico-legal  side  of  the  question.  It  may  happen  to  any  physi- 
cian to  be  called  upon  to  testify  upon  the  amount  of  injury  done  to  an  eye,  and, 


1878.]    Arlt,  Injuries  of  Eye  and  their  Medico-Legal  Aspect.  233 


if  he  is  not  conversant  with  the  specialty  in  question,  his  testimony  is  valueless. 
The  author  presupposes  that  the  physician  is  acquainted  with  the  modern  means 
of  investigation,  including  the  use  of  the  ophthalmoscope,  and  gives  the  very 
sound  advice  that  if  he  does  not  possess  these  requirements,  he  should  transfer 
the  case  into  the  hands  of  some  colleague  who  is  familiar  with  them.  He  depre- 
cates the  little  value  of  many  medico-legal  opinions,  in  which  the  existing  degree 
of  vision  and  its  changes  receive  no  mention. 

The  author  discusses  the  subject  briefly,  but  very  clearly,  under  four  heads : 
1.  Injuries  produced  by  sudden  compression  or  concussion  of  the  eye.  2.  Inju- 
ries produced  by  the  entrance  of  a  foreign  body,  not  acting  chemically.  3.  Scalds 
and  corrosions  of  the  eyeball.  4.  Affections  that  are  either  feigned  or  produced 
artificially  and  intentionally.  Of  these  four  classes  the  most  important  is  the 
second,  as  in  these  cases  the  foreign  body  may  be  lodged  in  the  eye,  or  at  either 
side,  or  behind  it,  or  it  may  not  remain  at  all.  Injuries  of  the  appendages  of  the 
eyeball  are  not  considered.  The  author  further  justly  emphasizes  the  necessity 
of  examining  the  functions  of  the  uninjured  as  well  as  the  injured  eye,  for  the 
latter  may  have  been  the  one  on  which  the  patient  relied  to  carry  on  his  work, 
and  if  sympathetic  inflammation  should  threaten  the  other  eye,  it  is  of  great 
advantage  to  have  noted  the  degree  of  vision  of  this  eye  at  the  time  of  injury. 
Another  reason  for  a  careful  examination  is  the  fact  that  abnormalities  are  some- 
times found  which  existed  without  the  patient's  knowledge  previous  to  the 
injury. 

The  author,  in  speaking  of  concussion,  takes  occasion  to  differ  with  Berlin  as 
to  the  cause  of  the  changes  occurring  at  a  point  opposite  the  seat  of  the  blow ; 
and  with  Knapp  on  the  subject  of  contrecoup.  His  explanation  of  rupture  of  the 
choroid  is  rational,  and  is  in  consonance  with  the  views  of  other  authors  of  note. 
In  each  division  of  the  subject,  the  injury  done  to  each  and  every  part  of  the  eye 
is  considered  separately,  and  afterwards  the  injury  to  the  eye  as  a  whole.  In 
this  way  we  obtain  a  very  complete  view  of  the  entire  field.  The  paragraphs  on 
injur}-  of  the  zonula  of  the  lens  are  exceedingly  good,  and  attention  is  called  to 
the  fact  that  a  trembling  or  undulation  of  the  iris  is  of  no  positive  value  as  a 
proof  of  a  movable  lens,  for  the  iris  may  oscillate  independently  when  its  pupil- 
lary margin  is  free,  and  there  is  more  aqueous  humour  behind  it  than  is  normally 
found  there.  Wounds  of  the  cornea,  with  prolapse  of  the  iris  and  cystoid  or 
ectasic  cicatrices,  form  an  important  part  of  the  second  division  of  the  volume, 
and  are  carefully  considered.  Wounds  of  the  lens  close  the  first  part  of  the 
second  division ;  and  the  second  part  is  devoted  to  wounds  where  the  foreign 
body  remains  behind.  This  is  by  far  the  most  important  part  of  the  entire  sub- 
ject of  injuries,  for  a  decided  opinion  upon  such  a  case  is  often  not  possible  until 
after  prolonged  observation.  Furthermore,  after  deciding  upon  the  presence  and 
situation  of  a  foreign  body,  the  question  of  removal  should  always  be  considered, 
not  only  as  to  its  possibility,  but  as  to  its  advisability.  Arlt  thinks  that  in  doubt- 
ful recent  cases,  which  can  be  kept  under  observation,  it  is  well  to  wait  a  few 
days  before  interfering;  but  he  also  believes  that  the  general  rule,  that  foreign 
bodies  should  be  rather  removed  early  than  late,  must  be  borne  in  mind.  In  this, 
as  in  other  branches  of  surgery,  experience  has  taught  us  that  strict  abstract  rules 
for  action  cannot  be  laid  down  for  all  cases,  but  that  each  case  will  inevitably 
modify  such  rules.  The  difficulties  of  the  situation  are  drawn  very  clearly  before 
our  eyes  by  the  author,  and,  as  far  as  is  possible  in  such  a  small  work,  discussed 
very  fully.  In  fact,  Professor  Von  Arlt,  in  the  preface,  states  that  he  regards 
what  he  has  here  written  as  mere  outlines,  which  he  thinks  might  serve  as  a  basis 
for  a  strictly  technical  and  exhaustive  monograph  upon  the  subject. 

So  much  for  the  work  itself,  and  we  will  now  turn  to  the  translation.     As  a 


234 


Bibliographical  Notices. 


[July 


whole  the  work  of  the  translator  has  been  fairly  carried  out,  but  there  are  a  great 
many  blemishes.  The  most  glaring  of  these  we  meet  with  before  opening  the 
book.  On  the  back  of  the  little  volume  we  read,  "  Injuries  of  the  Eye — Turn- 
bull"  !  !  In  other  words,  the  author  is  entirely  ignored,  and  the  translator  glori- 
fied. This  is  certainly  a  very  imprudent  piece  of  assumption,  to  call  it  by  no 
stronger  name.  The  title-page  is  correct,  which  renders  the  matter  worse. 
There  are  a  few  typographical  errors,  but  the  work  of  revision  has  been  very 
carelessly  done,  and  there  are  a  number  of  places  where  the  translation  is  too 
literal.  Thus,  on  page  3G,  "resolution  of  the  nidus  of  accumulation"  may  be 
German,  but  is  certainly  not  pure  English.  There  are  instances  of  tautology,  as 
on  page  51,  in  "maculous  spots."  On  page  79  another  literal  German  phrase  is 
"  refusal  of  the  pupil  against  atropine;"  but  this  is  not  English.  Such  words  as 
"reflectory"  and  "radiatory,"  though  perhaps  intelligible,  are  not  good  English, 
but  manufactured.  Foreign  words  are  introduced  which  are  to  many  unintelligi- 
ble, such  as  "serrae"  on  page  102,  and  " encheireses"  on  page  123.  There  is 
a  very  careless  piece  of  work  at  the  bottom  of  page  114,  in  the  last  sentence,  and 
one  of  the  most  awkward  translations  occurs  on  page  122,  in  the  words  "to  en- 
deavour an  exhaustion  of  the  lens."  Chapters  III.  and  IV.  are,  however,  very 
carefully  translated,  and  read  very  smoothly ;  and  the  book  is  a  valuable  contri- 
bution to  medical  literature  in  spite  of  these  blemishes.  C.  S.  B. 


Art.  XXIX. — A  Practical  Treatise  on  Aural  Surgery.  By  H.  Macnaugh- 
ton  Jones,  M.D.,  etc.,  Surgeon  to  the  Cork  Ophthalmic  and  Aural  Hospital, 
etc.  etc.    8vo.  pp.  174.    London:  J.  &  A.  Churchill,  1878. 

This  book  is  written  by  an  author  evidently  interested  in  otology,  and  deserves 
credit  for  some  well- written  parts,  as,  for  instance,  those  pertaining  to  the  man- 
agement of  the  Eustachian  catheter,  the  treatment  of  chronic  suppurative  inflam- 
mation of  the  middle  ear,  and  the  short  chapter  on  Othaematoma.  These  portions 
of  the  little  work  are  quite  good.  But  no  book  on  the  ear  is  worth  publishing 
without  more  anatomy  than  this  book  contains.  Then,  too,  there  should  appear 
in  a  book,  even  of  the  small  size  of  this  one,  a  more  complete  description  of  the 
appearance  of  the  membrana  tympani  both  in  health  and  in  disease.  Instead,  how- 
ever, of  some  hints  on  these  two  latter  and  important  topics,  the  author  launches 
his  reader  into  what  might  be  very  justly  called  a  pictorial  catalogue  of  instruments. 
It  is  true  that  the  pictures  are  prettily  drawn,  but  most  of  them  are  of  useless  in- 
struments, and  many  of  them  unknown  to  scientific  otology.  The  whole  number  of 
wood-cuts  in  the  book,  45,  are  of  some  kind  of  instrument.  The  book  appears  to 
have  been  written  hurriedly,  and  without  much  collateral  reading,  as  is  shown  in 
the  paucity  of  references.  Otology  is  not  confined  to  any  one  land  or  book  ;  it  is 
purely  catholic  in  this  respect.  That  the  book  is  written  hurriedly  is  also  evi- 
dent from  the  numerous  typographical  errors  and  ambiguous  phrases  which  mar 
its  pages. 

When  giving  directions  for  syringing  the  ear,  the  author  tells  his  reader  that 
"the  lobe  should  be  held  well  back"  (p.  108).  Such  a  procedure  would  be 
useless  to  the  surgeon,  aT.d  painful  to  the  patient,  especially  if  there  should  be  a 
fissure  between  the  lobe  and  the  cheek.  The  general  direction  to  draw  the  auricle 
upward  and  backward  by  gentle  traction  on  the  helix  would  have  been  the  proper 
advice.  On  the  same  page,  108,  a  description  of  what  the  author  terms  inflam- 
mation of  the  membrana  tympani  is  given,  but  in  which  it  is  not  easy  to  recog- 


1878.] 


J  o  x  e  s  ,  A  Practical  Treatise  on  Aural  Surgery. 


235 


nize  anything  but  a  typical  case  of  otitis  media  purulenta.  So  that  here  again 
confusion  must  till  the  mind  of  the  reader. 

Our  faith  is  a  little  shaken  either  in  the  power  of  observation,  or  in  the  knowl- 
edge, or  in  both,  of  the  author,  from  a  statement  which  appears  on  p.  33,  to  the 
effect  that  the  so-called  "  pyramid  of  light,  on  the  membrana  tympani,  is  situated 
where  the  short  process  terminates."  Now,  if  there  is  any  one  point  on  which 
anatomists  are  clearly  in  unison,  it  is  that  this  peculiar  reflection  of  light  is  seen 
at  the  end  of  the  manubrium,  or  long  process  of  the  malleus.  In  fact,  it  cannot  be 
anywhere  else.  The  description  of  the  light  spot,  however,  is  good,  with  this 
exception  respecting  its  position.  But  we  must  urge  accuracy  in  these  matters, 
as  in  all  matters  of  diagnosis.  On  p.  92  occurs  the  compound  word  "  corto- 
labyrinth." — the  "middle  corto-labyrinth."  Now,  as  this  word  is  unknown  to 
otology,  and  as  there  is  no  explanation  of  its  meaning  in  the  author's  text, 
great  obscurity  surrounds  it. 

On  p.  39,  Politzer's  bag,  as  modified  by  Allen,  of  London,  is  lauded ;  but  it 
may  be  no  more  than  fair  to  say  that  this  modification  has  never  been  accepted  by 
Prof.  Politzer,  simply  because  he  considers  the  nose-pad,  as  suggested  in  this  modi- 
fication, as  dirty — a  view  in  which  the  reviewer  heartily  coincides.  The  statement, 
on  p.  40,  that  "with  Politzer's  bag  we  can  diagnose  any  perforation  of  the 
membrane."  etc.,  should  contain  the  important  proviso,  if  the  Eustachian  tube 
is  pervious  to  air. 

On  p.  46  it  is  stated  that  hearing  the  tuning-fork  vibrating  on  the  vertex  better 
in  the  deafer  ear  warrants  the  presumption  that  there  is  mucus  in  the  tympanum. 
The  manner  in  which  the  tuning-fork  is  heard  would  not  of  itself  warrant  such  a 
presumption,  for  an  ordinary  chronic  catarrhal  process  without  mucus  in  the  ear 
gives  the  same  response  to  the  tuning-fork.  But  this  is  plain  enough  if  the  one 
fact  is  kept  in  mind  that  whatever  impedes  the  entrance  of  sound  to  the  ear  also 
impedes  its  exit.  Not  only  mucus  in  the  tympanum  does  this,  but  so  does  the 
ordinary  altered  condition  of  the  sound-conducting  parts  in  a  middle  ear  affected 
with  chronic  catarrh. 

We  are  astounded  at  the  author's  statements  respecting  the  use  of  the  Eus- 
tachian catheter  in  a  sensitive  nostril.  On  pp.  59,  60,  it  is  said  that  "in  some 
persons,  where  the  nostril  is  sensitive,  tender,  or  obstructed,  I  find  it  useful  to 
pass  a  soft  bulbous  bougie,  well  oiled,  once  or  twice  before  introducing  the  cathe- 
ter.'* We  are  to  understand,  then,  that  when  the  nostril  is  too  tender  to  permit 
the  entrance  of  the  slender  catheter,  we  can  make  matters  better  by  inserting  a 
bulbous  bougie  into  the  sensitive  passage.  We  regret  that  our  author  advocates 
the  surgeon's  blowing  his  breath  into  the  patient's  middle  ear  by  means  of  the 
Eustachian  catheter,  as  it  is  certainly  a  very  inelegant,  inconvenient,  and  need- 
less procedure.    In  some  cases  we  would  consider  it  indelicate. 

Chapter  VIII.,  tenotomy  of  the  tensor  tympani  (pp.  83-95),  is  chiefly  quoted 
from  Weber-Liel  and  Hartman ;  but  the  author  seems  ignorant  of  the  labours  of 
Gruber  and  J.  Orne  Green  in  connection  with  this  operation.  Yet  in  a  book  of 
this  size  why  quote  a  dozen  pages  on  a  questionable  operation,  and  call  the  whole 
a  chapter  ? 

Our  author  advocates  the  use  of  10  to  20  gr.  solutions  of  nitrate  of  silver  in 
otorrhcea.  Silver  solutions  of  this  strength  have  long  since  been  abandoned  by 
aurists,  especially  since  Schwartze  demonstrated  their  futility  and  the  great  ad- 
vantage of  using  stronger  ones.  It  is  a  common  thing  for  aurists  to  use  nitrate  of 
silver  in  solution  of  a  strength  varying  anywhere  from  50  to  480  grs.  to  the  fluid- 
ounce  of  water.  It  is  in  fact  admitted,  by  all  aurists  of  any  degree  of  authority, 
that  it  is  worse  than  useless  to  employ  weak  solutions  of  silver  in  the  ear. 

The  general  advice  respecting  the  employment  of  the  artificial  membrana  tym- 


236 


Bibliographical  Notices. 


[July 


pani  is  very  good  ;  but  when  the  author  alludes  to  the  pulsation  always  seen  in 
any  ear  where  fluid  is,  and  lays  great  stress  on  the  diagnostic  value  of  this  appear- 
ance, we  must  say  that,  although  where  such  pulsation  is  a  perforation  may  be, 
it  by  no  means  proves  that  a  perforation  exists  in  the  membrane.  Pulsation 
means  nothing  in  this  respect,  as  can  be  shown  by  putting  a  drop  or  two  of  water 
in  the  fundus  of  the  auditory  canal  when  the  membrana  tympani  is  intact.  The 
pulsation  of  the  heart  is  always  communicated  to  a  column  of  fluid  in  an  auditory 
canal,  whether  perforation  exists  or  not. 

We  do  not  desire  to  be  hypercritical,  but  in  the  present  day  some  inherent  evi- 
dence of  research,  originality,  or  literary  skill,  and,  if  possible,  of  all  of  these 
essentials,  is  demanded  of  every  new  book.  Yet  we  fail  to  see  in  this  any  more 
than  that  which  must  be  deplored  in  a  host  of  works  on  all  subjects  in  the  present 
day,  viz.,  that  the  subject  has  been  abused  in  the  house  of  its  would-be  friends. 
It  is,  in  fact,  impossible  to  see  wherein  otology  or  general  surgery  can  be  bene- 
fited by  such  a  book  as  the  one  whose  title  heads  this  notice.  C.  H.  B. 


Art.  XXX. — Insanity  in  Ancient  and  Modern  Life,  with  Chapters  on  its 
Prevention.  By  Daniel  Hack  Tuke,  M.D.,  F.R.C.P.  12mo.,  pp.  226. 
London:  Macmillan  &  Co.,  1878. 

A  work  like  this,  embodying  the  matured  conclusions  of  thoughtful  study  and 
extensive  personal  observation,  free  from  dogmatism  and  exaggeration,  from 
sensational  statements  and  vicious  logic,  is  always  welcome.  It  is  welcome,  not 
only  for  its  own  intrinsic  merits,  but  because  the  disease  of  which  it  treats  is 
medically,  legally,  morally,  and  socially,  of  immense  and  growing  interest  in 
every  civilized  community.  So  much  has  appeared  on  this  subject  abounding  in 
pernicious  errors,  that  the  value  of  a  good  book  like  this  can  scarcely  be  over- 
estimated. Most  diseases  are  regarded  as  belono-inrr  exclusively  to  the  domain  of 
the  physician,  whose  special  possession  is  disputed  only  by  the  quack  and  char- 
latan. The  idea  of  popularizing  medical  knowledge  has  never  been  strongly 
favoured  by  the  profession,  for  it  is  a  question  whether  any  expected  benefit  from 
the  process  is  not  more  than  balanced  by  the  effect  of  a  too  curious  introspection 
into  our  physical  condition.  Whatever  doubt  may  exist  on  this  point,  generally 
considered,  it  must  be  admitted  that  in  regard  to  mental  disease  popular  informa- 
tion is  rendered  highly  desirable  on  account  of  the  very  numerous  and  peculiar 
interests  which  it  involves.  It  is  not  solely  the  health  of  an  individual  that  is 
concerned,  but  also  the  health  and  welfare  of  his  offspring,  the  cause  of  humanity, 
the  good  order  of  society,  and  the  character  of  our  legislation  and  jurisprudence 
in  dealing  with  it.  Whoever,  therefore,  helps  to  enlighten  the  public  respecting 
insanity  is  a  public  benefactor,  especially  when  it  is  done  so  judiciously  as  it  is  in 
the  book  before  us.  The  need  of  such  instruction  is  becoming  more  and  more 
pressing  every  day.  Most  people  think  they  know  something  about  insanity.  They 
often  know  better  than  the  doctor  what  should  be  done  with  the  patient.  They 
are  profoundly  knowing  as  to  the  causes  which  produced  the  trouble.  In  courts 
of  justice  they  are  ready  to  say  with  more  than  the  confidence  of  an  expert  whether 
the  person  concerned  was  or  was  not  insane.  Many  of  them,  though  very  likely 
never  in  a  hospital  except  as  casual  visitors,  undertake  to  inform  the  public,  in 
papers  read  to  associations  bent  on  reforming  the  world,  how  the  patients  in  those 
institutions  should  be  managed.  And  when  a  hospital  is  to  be  established,  who 
but  them  are  competent  to  adopt  the  plans,  to  draw  the  specifications,  and  make 


1878.]  Tuke,  Insanity  in  Ancient  mid  Modern  Life. 


237 


the  contracts? — for  are  not  the  veterans  in  the  specialty,  the  men  who  have  spent 
their  lives  in  the  care  of  the  insane,  little  better  than  old  fogies,  running,  year 
after  year,  in  the  same  old  ruts?  Surely  these  things  show  some  need  of  popular 
enlightenment  respecting  insanity  and  the  insane. 

Dr.  Tuke  believes  that  of  late  insanity  has  been  steadily  increasing,  and  this, 
we  apprehend,  is  now  the  dominant  opinion  among  those  who  have  given  much 
attention  to  the  subject.  He  regards  the  disease  as  chiefly  one  of  the  products  of 
civilization,  which,  with  all  its  benefits  to  the  bodily  and  mental  health  of  the 
race,  has  introduced  habits,  practices,  and  appetites  greatly  prejudicial  to  both. 
As  such  agencies  have  always  existed,  in  a  greater  or  less  degree,  among  all 
races  making  any  pretensions  to  civilization,  he  seeks  for  a  confirmation  of  his 
opinion  in  the  historical  records  of  those  best  known  to  us.  Rich  in  his  stores  of 
ancient  learning,  he  finds  in  them  ample  proof  among  the  Jews,  the  Egyptians, 
the  Greeks  and  Romans,  of  the  existence  of  those  agencies  most  effective  in  the 
production  of  insanity, — intoxication,  defective  nourishment,  strong  moral  emo- 
tions, and  intellectual  strain.  Though  far  less  prevalent  and  active  than  in  modern 
times,  there  is  no  reason  to  doubt  that  they  had  their  legitimate  effect  in  impair- 
ing the  mental  energies. 

The  exigencies  of  modern  times  have  led  to  a  great  enlargement  of  these  nox- 
ious  agencies,  for  the  extremes  of  wealth  and  poverty,  the  moral  and  intellectual 
strain  in  the  perpetual  struggle  for  existence,  the  facilities  for  indulging  the 
coarsest  appetites  and  passions,  have  multiplied  and  strengthened  them  to  an  ex- 
tent unknown  in  ancient  times.  They  act  both  as  predisposing  and  exciting 
causes  of  insanity:  in  the  former  relation',  vitiating  the  quality  of  the  brain,  and 
in  the  latter  developing  this  impairment  into  overt  insanity  in  a  succeeding 
generation.  The  drinking  man  who  passes  along  till  the  day  of  his  death  without 
appreciably  failing  in  health  or  strength,  the  life-long  victim  of  misfortune  and 
poverty  battling  with  adversity  to  the  last,  the  merchant,  the  banker,  the  politi- 
cian struggling  for  the  prizes  of  life  under  the  varying  emotions  produced  by  the 
chances  of  success  or  failure,  without  utterly  breaking  down, — each  and  all  may 
transmit  a  heritage  of  cerebral  infirmity  waiting  only  a  fitting  opportunity  to  be 
transformed  into  actual  disease.  Our  social  conditions,  it  must  be  remembered, 
with  all  their  conservative  intluences,  abound  with  occasions  of  cerebral  deteriora- 
tion even  in  the  opening  years  of  lite.  Especially  are  those  industrial  employ- 
ments that  bring  together  the  old  and  the  young — men  with  grovelling  tastes  and 
degrading  habits,  and  boys  apt  and  eager  to  learn  in  the  only  school  within  their 
reach — sources  of  incalculable  mischief  in  that  direction.  "It  was  recently  ob- 
served by  Mr.  Mundella,"  says  Dr.  Tuke,  "that  the  lad  who  began  at  eight 
years  of  age  in  a  mine,  without  education,  and  who  was  associated  with  men 
whose  whole  ambition  was  a  gallon  of  beer  and  a  bulldog,  was  not  likely  to  grow 
up  to  be  a  Christian  and  a  gentleman."  Such  influences  continued  through  suc- 
cessive generations  must  leave  their  mark  on  the  vital  statistics  of  the  race. 
Looking  into  a  higher  social  stratum,  we  see  a  youth  pursuing  his  education  for 
years  under  a  dangerous  strain  of  his  mental  forces,  and  then  embarking  in  a 
business  career  that  tries  his  powers  of  endurance  by  its  rapid  alternations  of 
hope  and  fear,  of  failure  and  success.  Are  we  surprised  by  the  steadily  increasing 
returns  in  the  tables  of  mortality,  of  apoplexy,  paralysis,  and  cerebral  congestion  ? 
Competition,  which  is  the  animating  principle  of  this  our  modern  life,  looks 
askance  at  prudence,  moderation,  and  rest,  and  makes  no  provision  for  reserved 
force.  "The  great  drawback  and  great  misfortune  in  the  public  life  of  public 
men  at  the  present  day,"  says  Mr.  Gladstone,  as  quoted  by  Dr.  Tuke,  "is  that 
which  I  may  describe  by  the  word  excess."    Had  he  embraced  in  this  category 


238 


Bibliographical  Notices. 


[July 


all  other  classes  of  men  who  live  by  their  wits,  the  remark  would  not  have  been 
far  from  the  truth. 

And  how  shall  the  man  afflicted  with  the  ancestral  taint  prevent  its  fearful 
development  into  actual  and  active  disease?  Alas,  the  answer  implies  an  appeal 
to  a  kind  of  reason  and  forecast  that,  for  the  most  part,  has  but  a  loose  and  un- 
certain control  over  the  conduct  of  men.  If  we  were  expecting,  near  at  hand,  the 
visitation  of  some  deadly  zymotic,  and  if  high  authorities  had  proclaimed  the  cura- 
tive properties  of  a  certain  drug,  experience  tells  us  there  would  be  a  rush  upon 
the  shops  which  sell  it,  until  it  were  swept  from  the  market.  In  the  case  before 
us,  however,  we  meet  with  the  incredulity  and  disgust  of  the  ancient  king  when 
directed,  for  the  cure  of  his  malady,  to  a  remedy  destitute  of  every  element  of 
the  strange  and  marvellous.  In  answer  to  the  question,  Dr.  Tuke  can  find  no- 
thing better  for  the  text  to  his  discourse  than  the  advice  of  the  school  of  Salernum 
to  those  in  need  of  a  physician,  viz..  a  cheerful  mind,  rest,  and  a  moderate  diet. 
And  the  sermon  needs  to  be  scarcely  less  brief  than  the  text ;  for  when,  aided 
by  all  the  lights  of  modern  observation,  we  have  said  to  our  seeker,  avoid  all  em- 
ployments that  encroach  upon  the  ordinary  periods  of  rest,  and  those,  too,  that 
involve  an  amount  of  trial  and  responsibility  beyond  your  powers  of  endurance, 
engage  in  no  undertakings  likely  to  produce  apprehension  and  anxiety,  shun  those 
scenes  and  occasions  where  the  emotions  are  wrought  up  to  a  high  pitch  of  excite- 
ment, be  on  your  guard  against  any  strain,  moral  or  intellectual,  have  we  not  said 
everything  that  can  be  turned  to  any  practical  account?  Nothing  here  said, 
however,  need  discourage  the  reader  from  well  pondering  the  suggestions  of  Dr. 
Tuke.  I.  R. 


Art.  XXXI. — Montreal  General  Hospital:  Pathological  Report  for  the  Year 
ending  May  1,  1877.  By  William  Osler,  M.D.  Svo.  pp.  97.  Montreal, 
1878. 

The  first  pathological  report  from  a  Canadian  hospital,  as  this  modest,  unpre- 
tentious volume  is  declared  to  be  in  the  dedication,  is  one  not  unworthy  of  its 
source.  To  the  autopsies  made  under  the  editor's  supervision  in  the  hospital,  are 
added  a  few  cases  of  special  interest  from  private  practice. 

The  notes  of  cases  are  concise,  often  too  brief  to  be  satisfying  to  the  student  of 
histology  ;  in  fact,  very  few  microscopic  examinations  are  given.  For  instance, 
in  Case  LXXXIL,  of  cancer  of  the  brain,  lungs,  liver,  and  vertebral  bodies, 
the  statement  that  the  growth  Avas  cancerous  dismisses  the  consideration.  Whether 
or  not  this  was  established  by  microscopic  examination  does  not  appear;  certainly 
such  a  study  would  have  greatly  added  to  the  interest  and  value  of  the  report.  It 
would  also  have  greatly  increased  its  importance  from  a  physiological,  and,  indeed, 
a  diagnostic  point  of  view,  if  a  brief  mention  had  been  made  of  the  effects,  during 
life,  resulting  from  a  growth  occupying  the  superior  parietal  convolution  of  the 
right  side,  accompanied  by  small  masses  in  the  right  corpus  striatum  and  in  the 
left  thalamus  opticus.  This  omission  is  the  more  noticeable  from  the  fact  that 
such  clinical  information  has  been  supplied  in  some  of  the  other  cases  reported. 

It  would  also  be  interesting  to  know  the  histological  character  of  certain  second- 
ary growths  in  the  liver,  which  were  found  in  a  fatal  case  of  epithelioma  of  the 
tongue  (Case  XLII.)  ;  since  these  secondary  growths  in  this  situation  are  usually 
sarcomatous ;  but  it  is  acknowledged  that  epithelial  cancer  may  also  occur  in  the 
liver,  where  there  are,  strictly  speaking,  no  ordinary  epithelial  elements. 

As  most  of  the  interesting  cases  have  already  appeared  in  the  medical  journals. 


1878.]       Pathological  Report  of  Montreal  General  Hospital.  239 


present  analysis  of  them  is  unnecessary.  The  interesting  case  (LI II.)  of  aneurism 
of  the  hepatic  artery  (a  cut  of  which  is  given  as  the  frontispiece  of  this  volume), 
reported  by  Dr.  Ross  in  the  Canada  Med.  and  Surg.  Journal  for  July,  1877, 
has  been  already  brought  to  the  notice  of  the  readers  of  the  American  Journal.1 
"We  notice,  on  page  1G,  a  case  (XLIV.)  of  hypertrophy  and  dilatation  of  the 
heart,  without  valve  lesion,  although  the  patient  had  all  the  symptoms  of  chronic 
valvular  disease  and  a  systolic  murmur  to  the  left  of  the  sternum  at  the  third 
interspace.  The  cardiac  trouble  was  by  exclusion  decided  to  be  one  of  that  com- 
parative! v  rare  form,  first  pointed  out  by  Prof.  Da  Costa,2  where  strain  and  over- 
action  from  prolonged  muscular  exertion  lead  to  organic  disease. 

In  twenty  per  cent,  of  the  cases  examined,  fenestration  of  the  aortic  valves  ex- 
isted, but  in  only  seven  per  cent,  of  the  pulmonary  semilunar.  These  peculiar 
little  perforations  are  believed  to  be  either  congenital,  or  result  from  atrophy,  and 
generally  have  little  pathological  significance.  The  proportion  here  given  is 
largely  in  excess  of  ordinary  observation  ;  but  it  is  nevertheless  remarkable  that 
they  so  rarely  give  any  signs  during  life,  or  lead  to  serious  cardiac  disease. 

A  death  f  rom  the  rupture  of  an  aneurysmal  dilatation  of  a  branch  of  the  pulmo- 
nary artery  in  the  Avail  of  a  phthisical  cavity  is  reported  (Case  XLVIIL),  with  the 
observation  that  the  rupture  of  such  small  aneurisms  is  the  cause  of  hemorrhage 
in  most  of  the  cases  of  death  from  haemoptysis  in  chronic  phthisis.3 

In  connection  with  acute  pneumonia  there  is  a  case  of  death  from  intercurrent 
meningitis  (Case  X.),  and  one  (Case  XV.)  of  red  hepatization  associated  with  ex- 
tensive diphtheritic  colitis.  Dr.  Bristowe4has  already  called  attention  to  this  latter 
condition,  which  he  found  in  two  out  of  thirty  cases  of  secondary  pneumonia,  and 
in  five  of  sixteen  cases  of  the  primary  disease. 

Two  cases  of  pernicious  anemia  of  the  myelogenous  variety  are  given.  Of  these 
one  was  published  in  the  Transactions  of  the  Canada  Medical  Association5  for 
1877  ;  the  other  in  the  Canada  Med.  and  Surg.  Journal  for  March,  1877.  The 
study  of  these  cases  has  been  carefully  conducted,  and  the  reports  are  valuable 
contributions  to  pathology.  As  an  instance,  however,  of  the  fact  that  hyperplasia 
of  the  bone-marrow  does  not  constitute  the  disease,  being  not  uncommonly  found 
in  other  chronic  wasting  diseases,  we  notice  that  in  Case  VII.  (a  man  aat.  35,  where 
there  was  pulmonary  tuberculosis,  death  occurring  from  acute  tubercular  peri- 
tonitis), there  was  found  to  be  a  general  hyperplasia  of  the  bone- marrow.  Through 
some  oversight,  the  condition  of  the  blood  as  regards  its  relative  richness  in  cells 
is  not  mentioned ;  but  the  following  is  communicated  in  reference  to  the  medulla 
of  the  bones  : — 

"  That  of  the  long  bones  has  a  uniform  grayish-red  colour,  nowhere  having  the 
yellowish,  fatty  aspect  of  normal  marrow.  In  the  cancellated  portions,  and  short 
bones,  it  has  a  lighter  red  colour.  On  examination,  there  were  :  (1)  Red  blood- 
corpuscles,  presenting  considerable  differences  in  size,  some  hardly  the  ^oVtr"  hi 
diameter,  and  many  curiously  irregular  in  form.  (2)  Ordinary  marrow-cells  and 
lymphoid  corpuscles,  which,  together  with  the  blood-corpuscles,  constitute  the 
chief  mass  of  the  tissue.  (3)  Nucleated,  red  blood-corpuscles,  the  embryonal  or 
transitional  forms  of  Neumann,  of  which  in  each  specimen  examined  four  or  five 
examples  were  met ;  they  are  larger  than  the  ordinary  coloured  forms,  and  have 
usually  a  single  nucleus.    The  coloration  of  these  corpuscles  is  nearly,  if  not 


1  For  Oct.  1877,  p.  565. 

3  Confirmed  by  the  observations  of  Allbutt,  Meyers,  Seitz,  Thurn,  and  others. 

3  See  Ramussen,  Edinburgh  Med.  Journal  for  1868  ;  and  Powell,  Transactions  Lon- 
don Pathological  Society,  vol.  xxii. 

4  Transactions  Pathological  Society  of  London,  vol.  viii. 
s  Noticed  on  page  506  of  this  Journal  for  April,  1878. 


240 


Bibliographical  Notices. 


[July 


quite,  as  marked  as  in  the  ordinary  forms.  (4)  Cells  containing  red  blood-corpus- 
cles, of  which  a  few  examples  occurred.    There  are  no  mygloplaques." 

An  instance  of  the  rare  condition  of  hypertrophic  cirrhosis  of  the  liver  (Case  I.) 
in  a  drunkard  is  given  on  page  56,  with  microscopic  appearances ;  one  (Case 
LXXXIV.)  of  cancer  of  the  neck  of  the  gall-bladder,  with  gall-stones ;  and  a 
case  (LXXXVIII.)  of  suppuration  of  the  portal  vein  following  typhoid  fever, 
also  are  worthy  of  attention. 

The  editor  has  evidently  given  much  care  to  the  compilation  and  arrangement 
of  this  work  ;  and  is  to  be  complimented  upon  the  clear  style  of  the  reports,  and 
the  unusual  freedom  from  typographical  errors  which  so  frequently  disfigure 
works  of  this  kind  and  detract  so  greatly  from  the  pleasure  of  reading  them.  It 
is  to  be  hoped  that  these  pathological  reports  of  the  Montreal  General  Hospital 
will  continue  to  be  published,  so  as  to  preserve  the  records  of  cases  of  such  unusual 
interest  as  appear  in  the  first  volume  of  the  series.  F.  W. 


Art.  XXXII.  —  Mortuary  Experience  of  the  Mutual  Life  Insurance  Com- 
pany of  New  York,  with  Tabulated  Reports,  and  an  Analysis  of  the  Causes 
of  Death.  By  G.  S.  Wixstox,  M.D.,  W.  R.  Gillette,  M.D.,  and  E.  J. 
Marsh,  M.D.    Vol.  II.    8vo.  pp.  224.    Xew  York,  1877. 

This  work  'is  a  continuation  of  the  one  which  we  noticed  in  the  number  of  this 
Journal  for  July,  187G.  It  deals  much  less  with  numerical  facts,  and  more  with 
general  deductions  from  the  experience  of  the  company,  as  bearing  on  particular 
diseases.  A  large  amount  of  space  is  devoted  to  consumption,  with  results  ex- 
tremely interesting,  and,  in  some  respects,  surprising.  One  conclusion,  somewhat 
at  variance  with  the  general  impression,  is,  that  the  disease  prevails  with  about 
equal  frequency  at  all  ages,  from  twenty  to  sixty  years.  Above  the  latter  age,  it 
even  increases  as  a  cause  of  death.  In  the  especial  field  of  the  insured  lives,  the 
fatality  more  nearly  approaches  to  the  popular  idea ;  apparently  from  the  fact 
that  tendency  to  the  disease  is  much  less  discoverable  in  the  young  than  in  the 
middle-aged.  That  is,  a  young  pei'son  not  unfrequently  passes  rather  suddenly 
from  apparent  health  into  a  phthisical  condition ;  while  with  older  people  the 
onset  of  the  complaint  is  more  gradual  and  more  forewarned,  so  to  speak.  The 
latter  class  of  cases,  therefore,  are  detected  and  refused  as  risks  by  the  medical 
examiners,  while  the  former  are  accepted,  and  develop  their  malady  later. 

As  to  the  alleged  increased  proportionate  prevalence  of  phthisis  as  a  cause  of 
death  after  sixty  years  of  age,  we  would  suggest  that  mauy  old  people  have  a 
chronic  bronchitic  cough,  and,  dying  from  general  debility  or  old  age,  the  disease 
may  be  wrongfully  attributed  to  "consumption." 

The  protective  intiueuee  in  favour  of  the  company,  exerted  by  its  medical  exami- 
nations, is  shown  in  regard  to  this  disease  by  the  fact  that,  whereas  in  society  at 
large  phthisis  destroys  annually  35  out  of  10,000  adults  living,  within  the  circle 
of  the  insured  the  number  is  only  about  19.  The  effect  of  rigid  examination  is 
again  shown  in  the  small  number  of  phthisical  deaths  in  the  first  year  of  insur- 
ance. Thus,  to  10,000  lives  exposed,  but  7  die  in  the  first  year,  while  17,  21, 
and  25  to  each  of  the  succ  sealing  three  years  mark  the  development  of  disease, 
undiscovered,  and  probably  undiscoverable,  at  date  of  application. 

The  officers  of  the  company  have  been  unable  to  reach  any  conclusions  as  to 
the  influence  of  occupations  upon  phthisis. 

Chest-measure,  while  found  to  be  somewhat  less  in  consumptively  inclined  per- 


1878.] 


Mortuary  Experience  in  Life  Insurance. 


241 


sons  than  in  others,  is  here  regarded  as  an  indication  of  less  prognostic  moment 
than  is  the  weight  of  the  body,  in  its  proportion  to  the  stature.  Careful  observa- 
tions of  large  numbers  of  men  (among  them  the  U.  S.  Provost  Marshal's  obser- 
vations noticed  in  this  Journal  for  Oct.  1876)  have  established  a  standard  of 
normal  ratios  whereby  the  weight  of  body,  proper  to  each  height,  is  ascertained. 
Among  consumptives,  we  are  here  told,  80  per  cent,  fell  below  the  right  weight. 

Hereditary  predisposition,  or  "family  taint/'  has  not  seemed  to  these  writers 
worthy  to  exert  quite  so  strong  a  prohibitory  influence,  as  might  have  been  antici- 
pated, against  the  taking  of  risks.  By  itself  alone,  it  is  not  considered  decisive 
against  acceptance.  They  have  not  found  the  disease  earlier  developed  in  the 
tainted  than  in  those  free  from  known  predisposition. 

Haemoptysis,  it  would  strike  an  outsider,  is  here  a  little  overrated  as  condemna- 
tory of  an  application.  The  company  accepts  no  one  within  seven  years  after 
manifesting  this  symptom. 

Zymotic  diseases  have  a  peculiar  importance  to  insurance  companies,  inasmuch 
as  no  care  in  selection  can  avail  to  guard  against  losses,  and  as  the  causes  which 
produce  epidemics  are  wholly  beyond  their  control.  Some  forms  of  zymotic 
disease,  however,  but  rarely  attack  the  class  of  people  who  insure  their  lives. 
Hence  we  see  that,  while  typhoid  prevails  equally  among  the  insured  and  among 
the  general  city  population,  smallpox  is  at  7  to  48, 1  as  cause  of  death  in  these 
two  classes;  typhus  fever,  5  to  20 ;  dysentery  and  diarrhoea,  24  to  67;  and  re- 
lapsing fever  caused  no  deaths  in  the  company's  100,000  risks.  Altogether,  the 
zymotic  mortality  in  the  company  is  about  one-half  that  outside.  Conditions  of 
age,  and  the  fact  noticed  in  the  foot-note,  of  course  aid  in  producing  this  great 
difference,  which,  however,  seems  yet  to  be  chiefly  due  to  the  difference  of  class, 
as  first  referred  to. 

The  apparent  fact  of  a  company-mortality  from  alcoholism  of  6  against  a 
general  rate  of  68,  here  attributed  to  the  influence  of  careful  selection  of  risks, 
we  arc  inclined  to  discount  considerably.  The  unpleasant  word  in  question  is 
rarely  used,  however  appropriate,  in  the  social  class  to  which  the  company's 
clients  mostly  belong.  Every  medical  man  knows  how  very  many  terms  may  be 
employed  in  these  cases,  and  often  justified  more  or  less  by  the  symptoms,  to  avoid 
naming  the  ugly  condition  at  the  back  and  bottom  of  all  the  surface  symptoms. 
Indeed,  it  is  almost  impossible  to  disregard  the  feelings  of  surviving  friends  in  this 
matter. 

We  notice,  by  the  by,  that  our  authors  include  the  affection  just  named  among 
the  zymotics. 

Tables  of  deaths  by  decennial  periods  support  the  statement,  that  care  in  selec- 
tion of  risks  has  no  protective  power  against  losses  by  zymotic  diseases  generally, 
inasmuch  as  the  number  in  each  period  varies  but  little,  and  with  no  apparent  law. 

We  are  somewhat  surprised  to  learn  that  the  mortality  from  smallpox  is  much 
smaller  than  among  the  insured  of  the  German  companies,  in  the  ratio  of  2.3  to 
10,  in  the  most  fatal  years  of  each.  The  absolute  number  of  decedents  in  the 
"  Mutual"  from  this  cause  is  too  small  to  warrant  much  argument,  but  out  of  the 
company's  23  deaths,  in  1871-3,  12  were  foreigners,  including  8  Germans. 

Typhoid  fever  tables  indicate  that  deaths  from  this  disease  are  by  no  means 
proportionately  less  frequent  in  advanced  life.  In  fact,  to  100,000  lives  in  the  age- 
period  60-69,  there  are  just  double  the  number  of  decedents  from  typhoid  that 
are  found  from  30  to  39.  The  sequence  of  mortalities,  through  the  periods  as 
here  shown,  is  rather  curious.    Beginning  with  87,  from  20  to  29,  we  find  in  suc- 


1  This  difference  is  in  part  due  to  the  municipal  statistics  covering  fewer  years,  and 
yet  including  the  worst  period  of  epidemic  prevalence. 
No.  CLI  July  1878.  16 


242 


Bibliographical  Notices. 


[July 


cessive  decades,  52,  54,  58,  104,  86.  Thus  the  general  chances  of  death  from 
this  malady  seem  greatest  in  age  and  in  youth,  while  least  in  middle  life.  Are 
any  other  modes  of  ending,  among  the  old  and  debilitated,  possibly  liable  to  be 
mistakenly  reported  as  typhoid  ? 

A  very  large  and  somewhat  inexplicable  disproportion  seems  to  exist  as  to  can- 
cer, as  a  death-cause,  in  and  out  of  the  company.  In  the  lack  of  a  better,  may 
we  not  suspect  as  a  reason  for  exemption  the  better  food  and  sanitary  surround- 
ings of  the  class  that  insures  ? 

Diseases  of  the  nervous  system,  as  a  cause  of  death,  rapidly  increase  with  the 
age  of  the  insured.  Comparing  the  insured  with  the  uninsured,  the  mortality  to 
a  certain  number  living  is  decidedly  smaller  with  the  former.  Among  the  dying, 
in  the  respective  classes,  however,  those  from  nervous  diseases  bear,  to  the  total 
mortality,  a  larger  proportion  among  the  insured — owing,  probably,  as  here  sug- 
gested, to  the  extensive  exclusion  of  other  forms  of  disease,  such  as  consumption, 
for  instance,  by  the  company's  examiners.  That  the  actual  proneness  of  the  class 
which  insures,  to  fatal  nervous  trouble,  is  less  than  that  of  a  more  stolid  and  less 
intellectual  one,  is  an  occasion  for  some  comment.  The  present  writers  point  to 
superior  knowledge  of  laws  of  health,  better  food  and  shelter,  and  especially  to 
more  temperate  habits  as  to  drink,  as  the  probable  causes  which  overbalance  the 
greater  nervous  tension  and  wear  and  tear  resulting  from  the  severe  mental  and 
emotional  strain  attending  the  lives  of  the  professional  man  and  the  merchant. 

Deaths  by  apoplexy  are  fewer,  to  persons  living,  among  the  insured  than  out- 
side ;  in  both  classes  the  number  very  rapidly  increases  in  about  an  equal  ratio — 
doubling  with  every  ten  years  of  age. 

The  fact  and  comment  of  the  previous  publication  are  here  repeated  as  to  the 
greater  mortality  from  apoplexy  in  the  first  year  of  insurance  than  in  the  second. 
Fears  and  warnings,  more  or  less  vague,  perhaps,  led  persons  to  insure  their  lives 
without  mentioning  sensations  that  would  have  excluded  them  if  named.  The 
peculiarity  as  to  the  first  years  obtains  in  all  the  decennial  periods. 

Some  curious  and  interesting  researches  have  been  made  to  ascertain  whether 
or  not  some  recent  writers  are  right  in  setting  aside  the  idea  that  a  stout  and  short 
stature  favours  apoplectic  seizures.  The  company's  experience  decidedly  sup- 
ports the  more  popular  and  time-honoured  notion. 

In  regard  to  "softening  of  the  brain,"  we  think  the  compilers  might  wisely 
have  pursued  the  same  course  as  with  "disease  of  brain" — dismissed  the  matter 
as  too  vague  to  be  recognized  as  an  entity.  We  mean,  of  course,  the  manner  in 
which  the  term  is  ordinarily  applied — to  any  and  every  case  of  progressive  mental 
weakness. 

Apropos  to  the  question  of  insanity  and  suicide,  noticed  on  another  page  of  this 
Journal,  we  find  here  the  significant  fact  that  of  the  70  decedents  from  "in- 
sanity," 39  committed  suicide  !  Even  supposing  that  other  deaths  should  properly 
have  been  attributed  to  insanity — instead  of  "  brain  disease,"  or  some  intercurrent 
or  terminal  malady — this  extraordinary  proportion  speaks  in  trumpet-tones  of  the 
peculiar  weakness  (we  cannot  call  it  belief)  of  juries,  which  seem  to  have  no  other 
term  which  they  can  possibly  apply  to  suicide  than  those  sapient  words,  "tempo- 
rary insanity."  How  they  arrive  at  a  knowledge  of  its  temporary  character  we 
cannot  imagine,  unless  because  the  victim  passes  from  time  to  eternity. 

The  very  decided  proportional  infrequency  of  mortality  from  heart-disease, 
which  exists  in  the  earlier  years  of  insurance,  gradually  diminishes,  though  it 
never  wholly  disappears.  That  is,  among  persons  who  grow  old  in  the  company 
the  affection  becomes  more  and  more  prevalent.  And  its  frequency  increases  with 
age,  even  in  those  recently  insured. 

A  somewhat  remarkable  disproportion  exists  between  the  general  and  the  com- 


1878.] 


Axstie,  Use  of  Wines  in  Health  and  Disease. 


243 


pany  mortality  from  pneumonia.  Partly  to  selection,  but  especially  to  exemp- 
tion from  poverty,  hardship,  and  intemperance,  is  attributed  the  fact  that  deaths 
from  pneumonia  among  the  insured  are  only  from  one-third  to  one-half  the  num- 
ber, to  so  many  persons  living,  that  obtains  in  the  general  population  of  New  York 
City. 

It  is  a  sign  of  honest  purpose  and  a  right  spirit  to  make  here  one  or  two  ac- 
knowledgments of  erroneous  deductions  in  the  previous  publication.  The  sup- 
posed excess  of  casualties  among  the  young  as  compared  to  elder  people,  formerly 
charged  to  activity  of  life  and  recklessness  of  spirit,  is  hoav  stated  to  be  apparent 
rather  than  real,  arising  from  the  absence  of  many  other  death-causes  proper  to 
more  advanced  life.  The  interpretation  of  figures  is  a  very  difficult  art,  and  the 
acknowledgment  of  error  in  particulars  increases  our  faith  in  the  general  correct- 
ness of  the  work. 

In  connection  with  the  statements  regarding  insanity,  above  noticed,  we  may 
remark  that  the  total  number  of  deaths  by  suicide  was  G2  ;  so  that  there  were 
actually  23  not  adjudged  to  be  manifestations  of  insanity. 

We  have  far  from  exhausted  the  interest  and  value  of  this  volume,  and  can  only 
hope  we  have  not  misinterpreted  its  teachings.  B.  L.  R. 


Art.  XXXITI. — On  the  Use  of  Wines  in  Health  and  Disease.    By  France  E. 
Axstie,  M.D.,  F.R.C.P.    12mo.  pp.  74.    London :  Macmillan  &  Co.  1877. 

All  the  writings  of  the  late  Dr.  Anstie  form  instructive  and  interesting 
reading,  and  the  little  brochure  before  us  is  no  exception  to  this  rule.  As  indi- 
cated in  the  title,  the  work  is  divided  into  two  parts :  in  the  first,  on  the  use  of 
wine  in  health,  without  discussing  the  lawfulness  or  advisability  of  such  use, 
the  author  adopts  as  a  fact  "established  both  by  wide-spread  custom  and  by  the 
most  recent  physiological  research,  that  alcohol,  as  such,  has  its  legitimate  place 
in  the  sustentation  both  of  the  healthy  and  diseased  organism."  He  shows, 
however,  that  wines,  in  addition  to  being  first  and  more  especially  considered  as 
alcoholic  fluids,  contain  various  other  ingredients,  such  as  sugar,  acids,  salts, 
astringents,  and  the  fixed  and  volatile  ethers,  scarcely  less  worthy  of  study  in 
the  selection  of  wines  for  ordinary  use,  and  of  particular  value  in  their  application 
to  the  treatment  of  disease.  The  second  part  is  occupied  with  the  consideration 
of  the  uses  of  wines  in  acute  and  chronic  diseases,  sound  general  principles  being 
laid  down  to  govern  their  use  in  the  febrile  and  non-febrile  diseases,  severe 
hemorrhages,  acute  neuroses,  shock ;  and,  under  the  head  of  chronic  diseases,  in 
debility  from  failure  of  primary  digestion ;  in  defective  conditions  of  the  blood, 
such  as  ansemia,  chlorosis,  hydremia,  etc.,  not  yet  complicated  with  tissue 
change ;  in  phthisis,  and  the  wasting  diseases  of  childhood  ;  in  the  chronic  neu- 
roses of  the  aged  ;  in  exhausting  mucous  discharges,  and  in  chronic  suppuration. 
Here  again  the  author  shows  the  value  of  a  familiar  acquaintance  with  the  dif- 
ferent vinous  ingredients,  the  practical  application  of  which  is  well  illustrated  in 
the  following  passage  : — 

"  The  ethereal  constituents  of  wine  have  a  special  value  in  the  latter  stage  of 
severe  febrile  disease,  with  great  exhaustion  of  the  heart,  especially  when  com- 
bined with  sleeplessness.  On  the  other  hand,  a  low  alcoholic  strength  of  wine, 
together  with  the  presence  of  carbonic  acid,  as  in  the  finer  effervescing  wines,  is 
particularly  useful  in  cases  where  the  violence  of  the  fever,  the  nervous  prostra- 
tion, and  the  derangement  of  digestion,  are  out  of  proportion  to  the  gravity  of 
the  case  as  regards  danger  to  life  and  continuous  destruction  of  tissue." 


244  Bibliographical  Notices.  [July 

Finally,  the  book  may  be  recommended  as  containing  a  great  deal  of  informa- 
tion pleasantly  imparted,  of  value  not  only  to  the  practitioner,  but  to  those  who 
would  be  intelligent  wine  connoisseurs.  R.  M.  S. 


Art.  XXXIV. — Prescription  Writing,  Designed  for  the  Use  of  Medical  Stu- 
dents who  have  never  Studied  Latin.  By  Frederic  Henry  Gerrish,  M.D., 
Prof,  of  Materia  Medica  and  Therapeutics  in  the  Medical  School  of  Maine, 
etc.   Second  edition,  16mo.  pp.  51.   Portland:  Loring,  Short  &  Harmon,  1878. 

Any  attempt  to  give  instruction  in  the  important  but  much  neglected  art  of 
prescription  writing  is  worthy  of  encouragement,  since  there  is  no  denying  the 
fact  that  many  students,  partly  from  indolence,  but  chiefly  from  lack  of  oppor- 
tunity, leave  our  schools  utterly  ignorant  of  this  branch  of  practical  medicine. 
The  little  volume  before  us  is  especially  deserving  of  praise,  both  on  account  of 
its  being  an  effort  in  the  right  direction  and  because  it  is  very  carefully  and  cor- 
rectly written.  It  is  divided  into  two  sections,  the  first  containing  the  rules  for 
writing  prescriptions,  and  the  second  a  list  of  the  words  used  in  prescriptions. 
Every  medical  student  should  possess  this  book  and  make  himself  master  of  its 
contents  ;  many  practitioners,  too,  would  profit  by  the  directions  in  regard  to 
chirography.  L.  S. 


Art.  XXXV. — Annual  Report  of  the  Board  of  Health  of  the  City  of  Pittsburgh, 
for  the  Year  1877.    pp.  70.    Pittsburgh,  1878. 

We  find  here  reported  a  mortality  from  smallpox  of  269,  and  from  diphtheria 
of  401.  Neglect  of  vaccination,  principally  among  the  most  degraded  and  igno- 
rant classes,  is  named  as  the  cause  of  the  first  malady  prevailing  so  extensively. 
When  we  learn  that  the  total  mortality  was  but  3408,  from  all  causes,  the  fatality 
from  diphtheria  appears  truly  appalling.  From  this  report,  and  from  an  article  in 
a  daily  paper  purporting  to  be  an  address  before  the  Academy  of  Medicine  by 
Dr.  Snively  of  the  Health  Board,  there  appears  to  have  been  a  close  connection 
between  insufficiently  sloped,  uncleansed,  and  unventilated  sewers,  and  the  locality 
of  greatest  mortality  by  diphtheria.  And  the  commencement  of  excessive  fatality 
closely  followed  a  remarkably  heavy  rain  falling  in  a  few  minutes;  Several  simi- 
larly violent  showers  followed  within  a  few  weeks.  It  is  believed  that  sewer-gas, 
forced  into  houses  at  the  time  the  sewers  were  inundated,  caused  the  extraordinary 
number  of  cases  and  the  scarcely  less  extraordinary  concentration  of  the  disease 
in  certain  districts.  Previous  to  August,  the  disease  may  be  considered  to  have 
been  purely  sporadic,  judging  both  by  number  of  cases  and  their  distribution. 
Only  35  deaths  occurred  in  the  first  seven  months,  while  the  mortality  during  the 
last  five  months  reached  the  frightful  total  of  366.  The  annual  death-rate  from 
this  cause,  in  previous  years,  had  varied  from  fifty  to  eighty.  There  would  seem 
to  be  no  possible  doubt  that  there  existed  some  sort  of  connection  between  the 
epidemic  and  the  obstructed  or  sluggish  flow  of  sewage. 

Curiously  enough,  typhoid  continued  to  exhibit  the  gradual  decrease  of  mor- 
tality which  had  existed  for  several  years.  A  singularly  large  mortality  by 
whooping-cough  is  not  commented  upon  in  the  text  of  the  report.  136  deaths 
from  this  cause  are  reported,  against  24,  55,  79,  and  57  in  the  consecutive  years 
preceding.    Scarlatina  did  not  prevail  to  any  unusual  degree.  B.  L.  R. 


1878.]    Transactions  of  Medical  Society  of  State  of  New  York.  245 


Art.  XXXVI.— Handbook  of  Ophthalmology.  By  Prof.  C.  Schweigger,  of 
the  University  of  Berlin.  Translated  from  the  third  German  edition.  By 
Porter  Farley.  M.D..  Rochester,  X.  Y.  Svo.  pp.  555.  Philadelphia: 
J.  B.  Lippineott  &  Co.,  1878. 

We  have  lere  presented,  for  the  first  time,  to  the  English  reading  public  the 
well-known  Handbook  of  Schweigger,  of  which  the  first  edition  in  the  original 
appeared  in  1871.  The  preface  which  accompanied  the  first  edition  has  been 
omitted,  whether  by  the  author  or  translator  we  have  at  present  no  means  of  de- 
ciding ;  but  in  either  case  we  think  it  unfortunate,  inasmuch  as  our  author  clearly 
states  therein  that  his  readers  must  bring  with  them  the  necessary  knowledge  of 
optics,  anatomy,  and  physiology,  and.  furthermore,  that  he  by  no  means  expects 
to  enable  the  student  to  dispense  with  attendance  on  clinical  demonstrations 
and  lectures.  The  book,  therefore,  calls  for  the  most  careful  and  attentive  read- 
ing on  the  part  of  those  not  moderately  well  versed  in  the  subjects  of  which  it 
treats ;  and  this  is  all  the  more  necessary  on  account  of  the  terse  and  condensed 
style  of  the  author.  Indeed  we  cannot  read  far  without  recognizing  the  same 
vigorous  hand  and  trenchant  style  which  we  find  in  his  Lectures  on  the  Use  of 
the  Ophthalmoscope  (1864). 

Occasionally  it  seems  to  us  the  author's  own  enthusiasm  and  interest  in  special 
subjects  have  induced  him  to  expand  these  to  the  detriment  of  others  of  more 
practical  importance  to  the  profession  and  to  the  public.  Thus,  when  treating 
of  strabismus,  he  has  given  us  a  most  carefully  elaborated  discussion  of  the 
subject  of  the  ''suppression  of  retinal  images"  and  of  "identical  retinal  points," 
while  he  dismisses  briefly  the  increasing  prevalence  of  near-sightedness  in  schools 
and  colleges:  and.  indeed,  while  quoting  Cohu's  first  investigations  on  the  sub- 
ject, he  omits  all  reference  to  the  more  recent  statistics  thereon. 

At  every  turn,  however,  we  recognize  the  careful  practitioner  and  experienced 
observer,  and  the  book  fairly  bristles  with  useful  hints  to  those  reading  it  carefully. 
Dr.  Farley  has  done  his  part  of  the  work  well,  and  has  given  us  a  faithful 
reproduction  of  the  original.  W.  F.  X. 


Art.  XXXYTI. — Transactions  of  the  Medical  Society  of  the  State  of  New 
York  for  the  Year  1877.    8vo.  pp.  479.    Albany,  1877. 

The  large  and  handsome  volume  published  by  the  Xew  York  Society  has  very 
little  eloquence,  but  a  large  amount  of  practical  observation,  by  practical  men, 
and  for  practical  use. 

Prof.  R.  W.  Pease  earnestly  commends  the  treatment  of  urethral  stricture  by 
the  methods  and  instruments  employed  by  Dr.  Otis.  When  the  measurements 
are  carefully  made,  and  the  strictural  fibres  completely  divided,  so  as  to  restore 
the  normal  calibre,  he  asserts  that  the  cure  is  speedy  and  permanent,  without 
continued  use  of  bougies.  Forty-five  cases  are  tabulated.  These  appear  to  sup- 
port the  claims  made  for  the  treatment. 

Irido-choroiditis.  apparently  dependent  on  pyaemie  infection  after  child-birth, 
is  treated  of  by  Dr.  T.  R.  Pooley.    The  one  case  here  reported  proved  fatal. 

Recovery  from  a  puncturing  wound,  made  by  a  jagged  iron  fragment,  believed 
to  have  penetrated  the  liver,  as  well  as  the  lung  and  diaphragm,  is  reported  by 
Dr.  Parmelee.    The  eleventh  rib  was  divided  by  the  accident. 


24G 


Bibliographical  Notices. 


[July 


Two  gentlemen  report  recoveries  from  very  severe  cranial  fractures  at  the 
base.  One  case  was  a  lad,  the  other  a  very  young  man.  In  oner  serious  loss  of 
brain-substance  and  a  fungous  growth  occurred.  In  the  other  were  symptoms 
strongly  pointing  to  injury  of  the  connections  between  brain  and  cord.  Furious 
delirium,  as  if  from  meningitis,  appeared  in  this  latter  case.  In  the  other  pa- 
tient, paralysis  of  the  portio  dura  persisted,  while  affection  of  the  vision  and  the 
ocular  muscles  had  nearly  disappeared  at  date  of  report.  "We  presume  neither 
reporter  would  very  confidently  assure  the  continued  freedom  of  their  patients 
from  cerebral  symptoms.  As  to  the  acute  and  immediate  troubles,  however,  we 
may  call  them  recoveries. 

Dr.  Austin  Flint  very  ably  exhibits  the  reasons  which  lead  him  to  look 
upon  pneumonia  as  a  constitutional  disease  rather  than  a  local ;  a  specific  fever 
rather  than  a  circumscribed  inflammatory  lesion.  A  priori,  it  would  be  hard  to 
say  why  there  should  not  be  a  pneumonic  fever  as  well  as  variolous,  a  scarlet,  or 
an  intestinal.  Juergensen,  Dr.  W.  H.  Draper,  and  other  eminent  writers  have 
advanced  the  same  idea.  The  arguments,  as  here  very  briefly  but  forcibly  put, 
seem  to  us  almost  conclusive,  at  least  as  to  the  presumptive  truth  of  these  recent 
views.  From  the  notes  given  of  the  discussion  which  followed  this  paper,  it 
would  appear  that  the  notion  of  pneumonia  being  "an  essential  fever,"  with 
"a  characteristic  lesion  like  smallpox  or  scarlet  lever"  (quoted  from  Draper, 
with  approval),  caused  not  a  little  commotion  in  the  minds  of  the  more  conserva- 
tive members.  To  consider  lung  fever  the  effort  of  nature  to  eliminate  a  blood- 
poison  must  certainly  have  suggested  many  reflections  pregnant  with  conse- 
quences. 

Dr.  Mart  P.  Jacobi  presents  an  admirable  report  of  tAvo  instructive  cases  of 
masked  epilepsy.  The  account  very  well  illustrates — if  the  diagnosis  was  cor- 
rect, as  we  believe  Lhe  obscure  and  hidden  ways  in  which  this  terrible  disease  is 
sometimes  manifested,  or  rather  perhaps  we  should  say,  eoncealed. 

Dr.  McFarlaxd  notices  the  increasing  use  of  hypodermic  opiate  medication 
at  the  discretion,  or  indiscretion,  of  patients.  It  seems  to  us  that  he  has  not 
quite  strongly  enough  indicated  the  peculiar  and  singular  fascination  which  this 
mode  of  administration  has  for  its  devotees.  He  fully  recognizes  the  fact,  how- 
ever, that  the  "  opium  habit"  is  sooner  formed  through  the  hypodermic  than 
through  stomachic  exhibition.  Opium  "antidotes,"  of  late  so  much  vaunted  by 
circulars  and  other  methods,  are  believed  by  him  to  be  invariably  composed  of 
the  "hair  of  the  dog  that  bit"  their  unlucky  dupes.  A  friend  of  his  has  col- 
lected twenty-eight  different  "  opium  cure"  circulars.  At  least  five  of  these  are 
named  as  having  been  tested  chemically,  and  found  to  contain  opium. 

Fatty  embolism,  as  illustrated  by  a  fatal  case,  is  treated  of  by  Dr.  Wm.  H. 
Bailey.  A  trivial  flesh  wound  was  followed  by  deposit  of  pus  under  the  deep 
fascial  of  the  thigh,  great  constitutional  irritation,  dyspnoea,  delirium,  and  death. 
The  blood  was  found  loaded  with  fat-globules,  and  with  considerable  occlusion  of 
capillaries  in  the  lungs  and  liver,  caused  by  the  presence  of  these  minute  spheres. 

Believing  that  the  rage  for  novelty,  in  drugs  as  elsewhere,  leads  to  frequent 
neglect  of  useful  agents  longer  known,  Dr.  Pomeroy,  of  Xewark,  directs  at- 
tention to  the  virtues  of  muriate  of  ammonia  as  an  alterative  and  neurotic.  We 
are  inclined  to  agree  with  him  that  the  powers  of  this  remedy  have  been  some- 
what forgotten  of  late. 

Cases  of  sudden  death,  with  no  discoverable  lesion ;  operative  procedures  for 
relief  of  uterine  ailments,  cleft  palate,,  etc.,  with  drawings  of  instruments  ;  nitrite 
of  amyl  in  hooping-cough ;  the  relief  of  prostatic  obstruction  by  a  retained  cathe- 
ter, these  and  several  other  subjects  are  briefly  treated  in  a  suggestive  manner. 

B.  L.  R. 


1878.] 


247 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES 

IX  THE 

MEDICAL  SCIENCES. 


ANATOMY  AND  PHYSIOLOGY. 

Note  on  a  Congenital  Band  stretching  Across  the  Origin  of  the  Aorta. 

Mr.  Robert  Samuels  Archer,  Assistant  Physician  to  West  Derby  Union 
Hospital,  Liverpool,  records  (Dublin  Journal  of  Medical  Science,  May,  1878) 
the  following  note  of  a  specimen  which  was  procured  from  a  case  the  subject  of  a 
coroner's  inquiry:  — 

The  aorta  and  left  ventricle  having  been  slit  up  in  the  usual  manner,  a  band 
was  found  extending  right  across  the  aorta.  This  band  was  situated  just  above 
the  line  of  insertion  of  the  aortic  valves,  and  when  the  vessel  was  closed  must 
have  flapped  up  and  down  in  the  blood  current,  as  it  lay  quite  loose  and  slack 
when  the  cut  surfaces  were  approximated.  Arising  by  an  expansion  of  about 
half  an  inch  wide,  from  that  part  of  the  aortic  wall  which  lies  just  above  the 
junction  of  the  posterior  and  left  lateral  semilunar  valves  (its  origin  running  in  a 
diagonal  direction  from  below,  upwards  and  backwards),  it  gradually  became 
narrower  till  it  reached  its  insertion  at  the  junction  of  the  posterior  and  right  lat- 
eral cusp  of  the  valve.  Its  direction  thus  represented  a  cord,  dividing  the  cir- 
cumferential area  of  the  vessel  into  two  unequal  arcs,  the  anterior  containing  the 
right  and  left  semilunar  valves,  and  the  posterior  the  posterior  valve.  It  was 
apparently  composed  of  exactly  the  same  kind  of  tissue  as  the  valves,  which 
were  in  every  respect  normal  and  competent.  The  heart  and  aorta  appeared  in 
all  other  respects  to  be  quite  normal  during  life. 

There  were  no  clinical  observations  made  during  life  of  the  heart's  sounds  over 
the  aortic  area.  Mr.  Archer  believes  the  band  to  have  been  congenital,  and  de- 
veloped together  with  the  semilunar  valves,  and  he  regards  it  as  an  irregular  and 
supernumerary  cusp.  An  extensive  search  in  anatomical  literature  leads  Mr. 
Archer  to  believe  this  anomaly  to  be  extremely  rare,  if  not  quite  unique. 

Localization  of  Functions  in  the  Spinal  Cord. 
Luchsixger  has  recently  published  three  sets  of  experiments  bearing  on  this 
subject  {Pfiugef  s  Archiv,  Band  xvi,  Heft  9  and  10).  The  first  is  an  applica- 
tion to  the  spinal  cord  of  the  well-known  method  employed  by  Kussmaul  and 
Tenner  in  their  researches  on  the  brain.  When  the  posterior  half  of  the  cord  is 
suddenly  deprived  of  blood,  by  simultaneous  occlusion  of  the  abdominal  aorta  and 


248 


Progress  of  the  Medical  Sciences. 


[July 


the  subclavian  arteries,  convulsions  take  place,  strictly  limited  to  the  hinder  part 
of  the  body.  The  second  has  to  do  with  the  vaso-motor  apparatus.  The  rise  of 
arterial  pressure,  which  is  produced  by  arresting  the  entrance  of  air  into  the  lungs, 
is  usually  attributed  to  a  stimulant  effect  of  the  non-aerated  blood  upon  the  gene- 
ral vaso-motor  centre  in  the  medulla.  Luchsinger  shows  that  spasmodic  contrac- 
tion of  the  arterioles  may  be  produced  by  the  action  of  venous  blood  on  the  spinal 
cord  after  its  separation  from  the  medulla,  or  after  the  functional  vitality  of  the 
latter  has  been  abolished,  in  consequence  of  ligature  of  the  vessels  which  supply 
it  with  blood.  This  experiment  affords  proof  of  the  existence  of  independent 
vaso-motor  centres  in  the  cord.  Lastly,  it  is  usually  taught  that  in  picrotoxin, 
the  active  principle  of  the  Cocculus  Indicus,  we  have  a  poison  which  causes 
tetanic  spasms  by  its  selective  action  on  a  hypothetical  "convulsion-centre"  in 
the  medulla  oblongata.  Luchsinger  finds  that  it  may  cause  convulsions  in  a  part 
of  the  body  whose  innervation  is  derived  from  the  spinal  cord  alone,  and  con- 
cludes that  its  operation  is  not  restricted  to  any  single  "  convulsion  centre."  but 
is  coextensive  with  the  motor  elements  in  the  gray  matter  of  the  anterior  horns. 
The  general  inference  from  all  the  above  lines  of  inquiry  is  that  the  proximate 
centres  for  all  the  functions  of  the  trunk  are  situated  in  the  spinal  cord,  and  not 
restricted  to  its  upper,  highly  specialized  extremity. — London  Med.  Record,  May 
15,  1878. 


MATERIA  MEDICA  AND  THERAPEUTICS. 

Toxic  Properties  of  Carbolic  Acid  in  Surgical  Use. 

In  the  course  of  four  years'  experience  of  the  antiseptic  treatment,  Dr.KusTER 
(Berlin)  had  met  with  five  cases  of  poisoning  by  carbolic  acid,  four  of  which  were 
fatal.  On  examining  the  literature  of  the  subject,  he  had  found  seven  mild  cases 
of  carbolic  acid  poisoning  with  one. death,  and  thirteen  severe  cases  with  five 
deaths.  His  first  case  occurred  in  a  woman  aged  23,  who  had  a  stricture  of  the 
rectum,  in  the  treatment  of  which  the  parts  were  repeatedly  washed  with  a  2  per 
cent,  solution  of  carbolic  acid.  Tins  was  twice  followed  by  collapse,  which  was  so 
severe  the  second  time  that  she  only  recovered  after  employing  artificial  respira- 
tion for  an  hour.  She  died  soon  afterwards  of  pyaemia,  and  at  the  necropsy  a 
large  abscess-cavity  was  found  surrounding  the  rectum,  which  might  have  con- 
tributed to  the  retention  and  absorption  of  the  injected  fluid.  In  a  second  case, 
the  washing  out  of  an  empyematous  cavity  in  a  child  with  a  2^  per  cent,  solution 
of  carbolic  acid  was  followed  by  collapse,  and  death  in  three  hours.  In  a  third 
case,  a  woman,  aged  39,  had  pelvic  periostitb  and  discharge  of  pus  through  the 
bladder.  Incision  and  washing  out  of  the  cavity  with  solution  of  carbolic  acid 
were  followed  by  collapse  and  a  fall  of  temperature  to  35°  Cent.  (95°  Fahr.),  and  a 
second  irrigation  with  a  5  per  cent,  solution,  the  next  day,  was  followed  by  sudden 
death.  The  fourth  case  was  one  of  resection  of  the  hip  in  a  child  aged  four  and 
a  half,  who  died  unexpectedly  the  next  day.  The  fifth  death  occurred  in  a  woman 
aged  33,  who,  in  consequence  of  erysipelas  following  an  injury  of  the  leg,  had  a 
large  abscess  under  the  right  gluteus  muscle,  and  suppuration  of  one  knee.  Death 
took  place  four  hours  after  the  suppurating  cavities  had  been  opened  and  injected 
with  solution  of  carbolic  acid.  Not  being  able  to  ascribe  these  sudden  deaths  to 
shock,  he  made  some  experiments,  to  determine  the  question  whether,  as  was 
probable,  carbolic  acid  exerted  a  poisonous  action  in  such  cases.  It  had  already 
been  established  by  the  experiments  of  others  that  cold-blooded  animals  were 


1878.] 


Materia  Medica  and  Therapeutics. 


249 


killed  by  small  doses,  while  warm-blooded  animals  required  large  quantities,  ten 
to  twenty  grammes  (two  and  a  half  to  five  drachms),  according  to  the  French, 
while  Husemann  had  calculated  the  fatal  dose  for  dogs  at  0.5  per  mille  of  the 
weight  of  the  bod)'.  Dr.  Kuster  had  found  that,  in  relation  to  the  body- weight, 
the  smallest  immediately  fatal  dose  was  0.036  per  cent.,  the  largest  0.075  per 
cent,  of  a  five  per  cent,  solution  of  carbolic  acid  injected  into  the  blood.  The 
injection  of  seven  and  a  half  grammes  was  followed  by  trembling,  of  ten  grammes 
by  convulsive  movements,  and  of  fifteen  grammes  by  loss  of  consciousness ; 
half  an  hour  or  an  hour  later  the  animal  recovered.  Larger  doses  produced 
also  loss  of  reflex  irritability  ;  this  agreed  with  Salkowski's  experiments,  in  which 
irritation  was  first  produced  and  then  paralysis.  In  man,  as  in  cold-blooded  ani- 
mals, there  was  no  trembling,  but  there  was  the  well  known  dark  olive-green 
colouring  of  the  urine — a  hitherto  unexplained  phenomenon — -especially  after  the 
external  use  of  carbolic  acid  ;  there  were  also  gastric  symptoms,  headache,  ver- 
tigo, vomiting,  increased  secretion  of  saliva,  changes  in  the  pupils  (more  fre- 
quently mydriasis),  dysphagia,  a  rise  of  temperature  with  small  doses,  a  fall  with 
larger  doses,  and  a  rise  after  the  use  of  the  remedy,  or  a  further  fall  until  death 
occurred.  Dr.  Kuster  was  inclined  to  refer  the  so-called  aseptic  fever  of  Volk- 
mann  partly  to  the  action  of  carbolic  acid;  and  he  also  suspected  the  existence  of 
a  carbolic  marasmus,  leading  to  death.  Just  as  in  diseased  animals  small  doses 
led  to  fatal  poisoning,  so  in  anemic  subjects,  exhausted  by  loss  of  blood,  the  poison 
acted  more  intensely,  in  consequence  of  being  more  readily  absorbed.  Carbolic 
acid  was  especially  ill  borne  in  septic  fevers,  and  also  in  children,  who  were  often 
in  a  cachectic  state  when  brought  under  treatment.  There  was  a  local  as  well  as 
an  individual  predisposition  to  easy  absorption.  Pneumonia  and  oedema  of  the 
lungs  were  mentioned  as  sequelae  of  carbolism.  Glauber's  salt  had  been  recom- 
mended as  an  antidote,  but,  according  to  Dr.  Kuster,  was  useful  only  in  mild 
cases.  He  had  not  been  able  to  avert  death  by  following  carbolic  acid  injection 
by  an  injection  of  the  salt,  nor  by  injecting  a  mixture  of  the  two  in  solution.  He 
recommended  the  greatest  caution  in  the  use  of  carbolic  acid.  In  all  possible 
cases  he  substituted  for  it  chloride  of  zinc,  which,  even  when  used  in  strong  solu- 
tion (8  per  cent.),  did  not  interfere  with  union  by  the  first  intention.  .He  coun- 
selled caution  in  washing  the  abdominal  cavity,  and  advised  that,  for  children, 
the  strength  of  the  solution  of  carbolic  acid  should  not  exceed  1^  per  cent. 

Dr.  Lucke  believed  that  mild  forms  of  carbolism  were  frequent,  but  he  had 
never  seen  a  fatal  case.  The  peculiar  colour  of  the  urine  could  not  always  be 
taken  as  a  guide,  since  it  often  only  appeared  after  several  hours'  exposure  to  the 
air.  A  more  sure  test  was  the  use  of  sulphuric  acid  and  chloride  of  barium ;  the 
absence  or  deficiency  of  the  white  deposits  of  sulphate  of  baryta  indicated  that  a 
certain  amount  of  sulphocarbolic  acid  had  been  formed  (Sonnenburg).  In  his 
experience,  the  carbolic  acid  spray  produced  slight  toxic  symptoms.  He  also 
believed  that  he  had  met  with  a  carbolic  nephritis,  especially  in  children,  and  also 
in  an  adult. 

Drs.  Bardeleben,  Koexig,  and  Huter  had  never  observed  dangerous  car- 
bolism. The  former  recommended  mixtures  of  carbolic  acid  and  sulphate  of  zinc, 
and  jute  impregnated  with  a  5  per  cent,  solution  of  chloride  of  zinc ;  the  latter 
recommended  the  stronger  solution  of  carbolic  acid,  which  more  quickly  produced 
coagulation. 

Dr.  Olshausen  had  seen  in  a  parturient  woman  with  rupture  of  the  cervix 
uteri,  carbolism,  with  loss  of  consciousness,  mydriasis,  twitchings  of  the  muscles, 
but  with  normal  action  of  the  heart  and  respiratory  organs,  produced  by  once 
washing  the  uterus  with  a  strong  solution  of  carbolic  acid;  the  symptoms  appa- 
rently disappeared  after  three  hours.    Death,  however,  soon  followed,  in  conse- 


250 


Progress  of  the  Medical  Sciences. 


[July 


quence,  as  the  necropsy  showed,  of  the  passage  of  carbolic  acid  into  the  peritoneal 
cavity.  It  was  remarkable  that  an  unsparing  use  of  the  carbolic  acid  spray  was, 
as  a  rule,  borne  well,  while,  when  he  changed  his  dressings  for  the  first  time  at 
the  end  of  five  or  six  days,  the  result  not  unfrequently  was  the  appearance  of  car- 
bolic acid  in  the  urine.  He  could  only  explain  this  by  assuming  that,  under 
Lister's  dressing,  the  skin  was  relaxed,  and  its  absorbent  power  increased.  In 
another  lying-in  woman,  the  washing  out  of  a  pelvic  abscess  and  the  hourly  appli- 
cation of  pledgets  of  cotton- wool,  soaked  in  a  2  per  cent,  solution  of  carbolic  acid, 
were  followed  in  twelve  hours  by  carboluria  and  collapse  ;  the  use  of  a  5  per  cent, 
solution  on  the  next  day  was  followed  by  a  return  of  the  symptoms,  and  by  death. 

Dr.  IIahn  had  seen  the  application  of  carbolized  jute  in  a  case  of  gunshot  frac- 
ture of  the  arm,  followed  by  nephritis,  which  disappeared  when  the  treatment 
was  abandoned. 

Dr.  vox  Lancenbeck  recommended  great  care  in  the  use  of  carbolic  acid. 
In  some  persons  the  existence  of  idiosyncrasy  was  beyond  doubt.  He  had  met 
with  two  fatal  cases  of  carbolic  acid  poisoning  in  children  in  hospital  practice. — 
London  Med.  Record,  May  15,  1878. 

Therapeutical  Properties  of  Salicylic  Acid. 

H.  Kohler  gives  (Med.  Chir.  Rundschau,  Heft  9,  Jahrgang  18)  as  the  re- 
sult of  a  large  number  of  experiments  witli  salicylic  acid  and  its  salts:  1.  That  in 
febrile  conditions  both  salicylic  acid  and  sodium  salicylate  lower  the  temperature. 
2.  That  in  large  doses  salicylic  acid  depresses  the  respiratory  activity,  and  may 
even  cause  death  by  asphyxia.  3.  Salicylic  acid  does  not  exist  in  the  blood  in 
the  uncombined  state,  but  as  sodium  salicylate,  in  which  state  it  is  eliminated  in 
man  at  least  by  the  kidneys.  4.  Salicylic  acid  acts  as  an  antiseptic,  but  sodium 
salicylate  arrests  neither  fermentation  nor  putrefaction.  In  this  point  of  view  it 
is  remarkable,  so  long  as  we  admit  the  identity  of  the  action  of  antiseptics  and  of 
the  antifebrile  action  of  certain  drugs,  that  both  salicylic  acid  and  sodium  salicy- 
late lower  the  temperature  in  typhus,  articular  rheumatism,  and  the  febrile  state 
of  phthisical  patients.  K  hler  set  himself  the  task  of  determining  whether  sali- 
cylic acid  alone  or  both  it  and  its  salts  possessed  the  power  of  lowering  the  tem- 
perature in  healthy  dogs,  and  he  was  led  in  the  first  instance  to  notice  its  effects 
(a)  upon  the  respiration,  and  (&)  upon  the  circulation.  He  found  that  both  in 
dogs  and  in  rabbits  salicylic  acid  and  sodium  salicylate,  when  ingested  into  the 
stomach  or  injected  into  the  blood,  rendered  the  respiration  slower,  apparently 
by  depressing  the  excitability  of  the  sensory  nerves,  t.  <?.,  the  branches  of  the 
vagus  in  the  lung,  leading  to  asphyxia  by  carbonic  acid  poisoning.  In  regard  to 
the  circulation  he  found  that  when  quickly  injected  and  in  large  quantities  the 
blood  pressure  rapidly  sank  almost  to  zero,  followed  by  convulsions  and  death, 
or  in  some  instances  by  great  retardation  of  the  cardiac  movements,  with  sphyg- 
mogvaphic  curves  of  immense  height,  and  a  more  gradually  occurring  fatal  issue. 
The  causes  of  this  depression  lay  in  the  heart  itself,  and  appeared  to  be  due  to 
the  action  of  the  drug  on  the  ganglionic  apparatus  or  to  paralysis  of  the  mus- 
cular tissue  of  the  heart.  In  regard  to  sodium  salicylate,  though  not  acting  so 
rapidly  or  powerfully  as  salicylic  acid,  its  effects  are  essentially  the  same.  The 
cardiac  branches  of  the  pneumogastric  have  their  excitability  lowered,  and  be- 
fore death  are  entirely  paralyzed,  and  the  same  results  occur  from  the  ingestion 
of  sodium  salicylate  into  the  stomach  as  from  the  injection  of  salicylic  acid  into 
the  blood.  In  regard  to  the  distribution  of  temperature  he  found  that  in  healthy 
rabbits,  cats,  and  dogs,  the  injection  of  from  six  to  ten  cub.  cent,  of  salicylic  acid 
or  sodium  salicylate  into  the  jugular  vein,  or  the  ingestion  of  from  ten  to  twenty 
cub.  cent,  of  solution  of  sodium  salicylate  into  the  stomach,  caused  a  depression  of 


1878.] 


Materia  Medica  and  Therapeutics. 


251 


temperature  of  about  three  degrees  Centigrade  (or  5°  Fahr.)  just  as  occurs  in 
man  during  the  febrile  state.  But  inasmuch  as  the  sodium  salicylate  does  not 
possess  any  antagonistic  properties  to  fermentation  and  putrefaction,  whilst  sali- 
cylic acid  is  immediately  converted  into  sodium  salicylate  after  absorption,  there 
is  strong  reason  for  not  regarding  antiseptically  acting  substances  as  being  also 
antipyretic.  The  diminution  of  temperature  observed  after  their  administration 
can  only  be  partially  examined  by  the  above-mentioned  modifications  of  the 
functions  of  respiration  and  circulation,  though  it  undoubtedly  goes  hand  in  hand 
with  them  ;  possibly  it  may  be  due  to  some  influence  on  the  vaso-motor  nerves 
leading  to  dilatation  of  the  peripheric  vessels,  and  consequent  lowering  of  the 
temperature  of  the  blood;  this  hypothesis  affords  an  explanation  of  the  conges- 
tions of  the  head,  singing  in  the  ear,  profuse  perspirations,  and  diuresis  observed 
in  many  animals. 

From  all  this  the  following  conclusions  may  be  drawn  :  1.  That  it  is  only 
when  externally  or  topically  applied  that  salicylic  acid  acts  antiseptically. 
2.  When  salicylate  acid  is  ingested  by  the  mouth  it  loses  its  antiseptic  action 
because  it  becomes  united  with  an  alkali,  and  it  then  only  acts  on  the  economy 
like  sodium  salicylate  when  taken  internally.  3.  Both  salicylic  acid  when  taken 
internally,  and  salicylate  of  soda,  though  destitute  of  any  antiseptic  action,  are  yet 
capable  of  depressing  the  temperature  of  the  body  in  febrile  conditions  to  an 
extent  unapproachcd  by  any  other  remedy. 

As  rules  for  practice  Kohler  considers  that  salicylic  acid  is  exclusively  to  be 
used  as  a  topical  antiseptic,  and  in  this  point  of  view  it  is  extremely  valuable  in 
diphtheritis  of  the  tonsils,  pharynx,  and  nose,  where  it  may  be  applied  in  the 
form  of  solution  containing  one  part  in  three  hundred.  Also  as  a  prophylactic 
remedy  in  infectious  blennorrhoeas,  in  leucorrhoea,  and  chronic  cystitis,  and  in 
dysentery  and  diarrhoea  ;  and  it  is  also  useful  in  dyspepsia  and  the  migraine  ac- 
companying it,  preventing  fermentative  processes  in  the  stomach  ;  for  this  pur- 
pose the  ferro-salicylate  is  best  adapted.  Sodium  salicylate  can  be  more  readily 
used  on  account  of  its  greater  solubility.  One  drachm  and  a  half  may  be  given 
once  or  twice  in  twenty-four  hours,  which  acts  more  promptly  in  reducing  the 
temperature  in  fever  than  quinine  and  cold  water.  Its  lowering  action  on  the 
temperature  very  rarely  fails  in  acute  articular  rheumatism,  diphtheritis,  typhus, 
or  local  inflammations.  Singing  in  the  ears  and  deafness  are  the  only  inconve- 
niences that  occur  from  the  use  of  sodium  salicylate. — Practitioner,  May,  1875. 

Action  of  Thermal  Applications  to  the  Skin  upon  the  Circulation  in  the  Brain 

and  other  Organs. 

In  the  Practitioner,  April,  1878,  the  views  of  Dr.  Winternitz  upon  the 
rationale  of  the  action  of  hot  applications  to  the  skin  are  expounded,  and  the 
experiments  upon  which  these  views  are  based  are  described.  It  was  found  by 
Golz  that  by  repeatedly  percussing  the  abdomen  of  a  healthy  frog  the  heart  can 
be  made  to  pulsate  more  slowly,  and  may  even  be  made  to  stop  altogether.  When 
the  tapping  ceases,  the  heart  generally  remains  for  some  little  time  in  a  state  of 
stand-still,  and  when  it  again  begins  to  pulsate  its  condition  is  the  same  as  if  the 
animal  had  lost  an  enormous  quantity  of  blood.  The  venae  cavas  remain  almost 
empty,  the  circulation  in  the  web  ceases,  and  arteries  which  are  cut  through 
hardly  bleed  at  all.  Where,  then,  i&  all  the  blood,  since  no  vessel  has  been  in- 
jured, and  no  blood  whatever  has  been  lost?  Golz  found,  on  post-mortem 
examination,  that  the  vessels  of  the  mesentery,  and  especially  the  veins,  were 
enormously  distended,  although  none  showed  a  solution  of  continuity,  showing 
that  the  vaso-motor  nerves  were  paralyzed,  and  these  vessels  consequently  dilated. 


252 


Progress  of  the  Medical  Sciences. 


[July 


Tension  thus  being  decreased  in  the  partially  emptied  vessels,  the  heart  becomes 
more  and  more  affected. 

A  similar  result  follows  the  division  of  the  splanchnic  nerves,  as  shown  by  Asp, 
von  Basch,  and  others,  when  all  other  parts  of  the  body  are  drained  excepting 
the  district  of  dilatation,  so  that,  in  the  eye,  the  contraction  of  the  retinal  vessels 
is  clearly  seen  after  division  of  the  splanchnics.  Thus  we  see  that  in  the  abdo- 
minal vessels,  controlled  and  regulated  as  they  are  by  the  splanchnic  nerves,  we 
have  an  apparatus  for  regulating  the  blood- pressure  in  the  body  generally,  and 
that  increased  tension,  in  any  vascular  district  of  the  body,  may  be  compensated 
by  dilatation  of  the  abdominal  vessels.  The  whole  so-called  derivative  method 
depends  upon  the  principles  just  sketched. 

The  utility  of  local  and  general  thermal  applications  to  the  surface  of  the  body 
has  long  been  recognized,  but  the  rationale  of  their  action  has  only  recently 
been  scientifically  established  by  the  experiments  of  Schttller.  He  carefully  tre- 
phined a  rabbit  on  both  sides  of  the  sagittal  suture,  and  observed  the  vessels  of 
the  pia  mater.  Mechanical  pressure  over  the  abdomen  caused  venous  congestion 
of  the  pia  mater.  Pieces  of  ice  laid  upon  the  dura  mater  caused  powerful  con- 
traction of  all  the  vessels.  Where  the  superior  cervical  ganglion  of  the  sympa- 
thetic had  been  removed,  the  application  of  ice  produced  no  effect  on  that  side. 
A  cold  wet  compress  on  the  belly  or  back  of  the  animal  produced,  almost  without 
exception,  immediate  and  persistent  dilatation  of  the  arteries  and  veins  of  the  pia 
mater. 

A  warm  wet  compress  applied  to  the  belly  or  back  had  a  contrary  effect.  The 
vessels  contracted  less  vigorously,  the  respiration  became  quicker  and  shallower. 
Plunge-baths,  hot  and  cold,  have  an  analogous  but  more  powerful  effect  than 
compresses. 

A  young  man  lay  two  hours,  naked,  on  a  bed  covered  with  a  blanket :  then  a 
thermometer  was  placed  in  the  auditory  meatus,  another  in  the  axilla,  and  a 
third  in  the  rectum.  After  the  thermometer  had  indicated  a  constant  tempera- 
ture for  some  time,  compresses  were  placed  on  the  legs,  reaching  from  the  foot  to 
the  knee.  After  fifteen  minutes  the  ear  thermometer  began  gradually  to  sink, 
and  reached  its  lowest  point  after  fifty-five  minutes,  falling  as  much  as  0.4°  C. 
(0.72°  Fahr.).  In  the  axilla  the  minimum  loss  of  heat  was  only  0.2°  C,  while 
in  the  rectum  the  temperature  rose  2.0°  C. 

A  further  communication  is  promised  upon  this  interesting  subject. — London 
Med.  Record,  May  15,  1878. 


MEDICINE. 

Myelogenic  Leucocytkcemia. 
As  the  result  of  a  long  discussion  of  cases  and  opinions  (Berliner  Klin. 
Wochenschi'ift,  Nos.  6,  7,  9,  10,  1878),  Professor  Neumann,  of  Konigsberg, 
points  out  that  the  following  conclusions  are  warranted  as  to  the  connection  be- 
tween leukaemia  and  changes  in  the  marrow  of  the  bones  :  1.  There  are  cases  of 
leukaemia,  for  the  development  of  which  no  cause  can  be  assigned  but  disease  of 
the  bone-marrow.  Hence  they  may  be  considered  as  examples  of  pure  myelo- 
genous leukaemia.  2.  No  case  of  leukaemia  has  as  yet  been  described  in  which 
on  examination  the  marrow  of  the  bones  has  been  found  normal.  Hence  there 
is  no  objection  to  the  view  that  leukaemia  is  constantly  associated  with  a  patho- 
logical alteration  of  the  marrow.    3.  The  ordinary  view  that  a  leukaemia  can 


1878.] 


Medicine. 


253 


originate  in  disease  of  the  spleen  or  lymphatic  glands  requires  to  be  re-examined 
and  tested,  since  the  proofs  formerly  adduced  in  favour  of  it  took  no  account  of 
the  marrow  of  the  bones.  Of  late,  not  a  single  case  has  been  observed  in  which 
the  possibility  of  disease  of  the  bone-marrow  could  be  excluded,  and  the  leukaemia 
proved  to  be  of  purely  splenic  or  lymphatic  origin,  with  the  same  certainty  as 
has  been  done  for  the  bone-marrow  in  a  case  of  Dr.  Litten's.  of  Berlin,  where 
there  was  not  a  trace  of  disease  in  the  spleen  or  lymphatic  glands.  Professor 
Neumann  regards  the  bone-marrow  as  "  an  organ  which  in  every  case  of  anaemia 
becomes  the  seat  of  important  alterations  which  disturb  its  physiological  equi- 
librium." These  alterations,  he  thinks,  consist  in  a  sort  of  compensatory  in- 
crease of  its  physiological  haematopoietic  function,  so  that  the  deficiency  of  red 
blood-corpuscles  in  the  general  circulation  is  filled  up  by  an  excessive  develop- 
ment of  white  cells  in  the  marrow  ;  the  final  result  being,  if  the  anaemia  persist, 
a  pathological  hyperplasia.  "Thus,"  he  says,  "  it  is  possible  that  the  transition 
of  a  variety  of  anaemic  conditions  into  leukaemia  may  be  brought  about  through 
the  medium  of  the  bone-marrow."  Of  course  there  is  at  present  but  a  small 
basis  in  fact  for  this  hypothesis,  but  it  may  nevertheless  direct  attention  to  a  new 
line  of  investigation  which  may  eventually  prove  fruitful  in  results. — Med.  Times 
and  Gaz.,  May  18,  1878. 

Contribution  to  the  Pathology  of  Hcemophilia. 
Mr.  P.  Kidd,  in  a  paper  read  before  the  Royal  Medical  and  Chirurgical  So- 
ciety of  London  {British  Med.  Journal,  May  25,  1878),  gives  a  description  of  a 
case  of  haemophilia  in  a  child  six  years  old,  in  which  fatal  hemorrhage  occurred 
from  the  mucous  membrane  of  the  mouth.  A  short  clinical  history  of  the  case 
was  given,  with  an  account  of  the  post-mortem  examination.  The  blood  was 
examined,  and  was  found  to  be  very  watery,  and  to  contain  a  large  excess  of 
colourless  corpuscles.  A  microscopical  examination  was  made  of  the  aorta  and 
vena  cava,  and  of  that  part  of  the  mucous  membrane  of  the  mouth  from  which 
the  fatal  bleeding  took  place.  This  examination  revealed  an  extensive  affection 
of  the  small  vessels,  arteries,  veins,  and  capillaries,  especially  the  smallest  veins. 
This  affection,  which  mainly  consisted  in  a  great  proliferation  of  the  epithelioid 
cells  lining  the  vessels,  was  seen  in  the  small  vasa  vasorum  of  the  aorta  and  vena 
cava,  as  well  as  in  the  vessels  of  the  submucous  tissue  of  the  mouth.  The  coats 
of  the  aorta  and  vena  cava  themselves  were  healthy.  Drawings  were  given  of 
the  affected  vessels  and  also  of  a  portion  of  the  surface-epithelium  of  the  mouth, 
which  had  undergone  a  peculiar  change,  described  in  the  paper.  A  certain  num- 
ber of  small  arteries  of  the  oval  mucous  membrane  had  undergone  a  further  change 
in  addition  to  the  epithelioid  proliferation.  This  consisted  in  a  degeneration  of 
their  muscular  coat,  which  was  seen  to  contain  only  a  very  small  proportion  of 
its  normal  structural  elements.  The  conclusion  was  drawn  that  in  this  case  there 
was  a  general  disease  of  the  small  vessels.  But,  as  the  blood  was  also  affected, 
there  still  remained  the  question  whether  this  was  primarily  a  disease  of  the  blood 
or  of  the  bloodvessels. 

Spinal  Gout. 

Dr.  Olliver  communicated  (Gaz.  Hebdom.,  May  17)  to  the  Academie  de 
Medecine  a  case  of  gout  in  which  he  found  in  the  spinal  canal  appearances  due  to 
a  uratic  infiltration  at  the  external  surface  of  the  spinal  dura  mater — exhibiting, 
therefore,  the  characters  of  true  visceral  gout.  These  spinal  manifestations  have 
hitherto  been  rather  suspected  than  described  ;  and  in  none  of  the  cases  related 
was  there  furnished  any  proof  of  their  gouty  nature.  Until  now,  in  fact,  their 
essential  character — the  deposition  of  granules  of  urate  of  soda — had  never  been 
demonstrated.— Med.  Times  and  Gaz.,  May  25,  1878. 


254 


Progress  of  the  Medical  Sciences. 


[July 


Writer's  Pals?/  Cured  by  Strychnia. 
At  a  late  meeting  of  the  Medico-Chirurgical  Society  of  Edinburgh  (Edinburgh 
Med.  Journal,  May,  1878),  Mr.  Annan  dale  showed  a  patient  who  a  few 
weeks  ago  had  suffered  from  writer's  palsy.  His  medical  attendant  had  tried 
strychnia  internally  and  galvanism  without  effect.  Having  studied  Bianci's  paper 
on  the  subcutaneous  injection  of  strychnia,  he  resolved  to  try  the  method.  Be- 
fore beginning  the  injections  the  patient  suffered  from — 1.  Want  of  power  in 
hand;  2.  Spasmodic  flexion  of  thumb  Avhen  writing;  and  3.  Pain  in  back  of 
neck.  Nine  subcutaneous  injections  had  been  made  into  the  flexors  and  exten- 
sors of  the  forearm,  with  the  result  of  complete  restoration  of  power,  removal  of 
pain  at  back  of  neck,  and  partial  improvement  of  flexion  of  thumb.  A  splint 
was  now  being  used  to  remedy  the  last.  Specimens  of  the  patient's  handwriting 
before  and  after  treatment  Avere  shown.  Prof.  Annandale  explained  that  the 
hypodermic  injection  consisted  of  equal  parts  of  liquor  strychnia  (B.  P.)  and 
water.  Of  this  6  mm.  were  injected  every  second  day,  the  dose  being  increased 
by  1  mm.  till  it  amounted  to  12  mm. 

Spasmodic  Spinal  Paralysis  in  Infants. 
Professor  Err,  of  Heidelberg,  remarks  (Betz's  Memorabilien,  vol.  xxii.  pt. 
12)  that  spasmodic  spinal  paralysis  in  infants  is  more  frequent  than  is  usually  sup- 
posed, and  is  often  misunderstood.  It  is  frequently  regarded  as  of  cerebral  ori- 
gin, or  as  connected  with  the  cerebral  derangements  of  childhood  ;  an  error  to 
be  avoided  without  difficulty  by  accurate  observation.  Symptoms  of  spasmodic 
spinal  paralysis,  complicated  with  previous  paralysis  of  the  arm,  and  distortion 
of  the  face,  and  coexistent  with  strabismus,  unquestionably  point  to  a  cerebral 
origin.  More  rarely  is  it  confounded  with  atrophic  spinal  paralysis  (tabes  dor- 
salis  proper)  which  is  characterized  by  its  sudden  onset,  by  marked  atrophy,  by 
shortcoming  and  deformity  of  the  limbs,  and  by  the  absence  of  reflex  and  gal- 
vanic irritability.  The  affection  is  developed  slowly  and  insidiously,  without 
convulsive  or  apoplectic  symptoms.  The  legs  are  moved  with  difficulty,  they  are 
clumsy  and  stiff,  and  retained  by  the  tense  or  contracted  muscles  in  certain  lixed 
positions.  Usually  the  child  cannot  walk  at  all,  but  yet  can,  when  lying  down, 
move  the  legs  though  with  some  difficulty.  If  the  child  be  supported  under  the 
arms,  attempts  at  walking  are  made,  but  the  thighs  are  closely  pressed  together, 
the  knees  slightly  bent,  the  feet  stretched  out,  so  that  only  the  points  of  the  toes 
touch  the  ground,  and  in  progression  the  feet  are  continually  crossed  and  stumble 
one  over  the  other,  or  in  slight  cases  are  dragged  along  the  ground.  Standing 
still  is  usually  possible  without  difficulty,  with  some  support.  The  skin  is  nor- 
mally sensible,  as  also  the  reflex  sensibility ;  the  feet  are  mostly  cold.  The  upper 
extremities  are  generally  unaffected,  likewise  the  brain  and  cerebral  nerves.  The 
intellect,  speech,  and  movements  of  the  eye  are  perfectly  normal.  The  general 
health  and  nutrition  are  usually  good,  and  there  is  an  entire  absence  of  atrophy. 
Dr.  Erb  describes  two  typical  cases  of  children  under  five  years  of  age  present- 
ing the  above  symptoms.  In  both  there  was  total  inability  to  walk,  and  the 
peculiar  and  characteristic  position  of  the  thighs  and  feet  was  strongly  marked, 
and  there  was  also  some  difficulty  and  indistinctness  of  speech — while  both  seemed 
otherwise  in  perfect  health.  Both  presented  a  close  resemblance  to  the  locomo- 
tor ataxy  of  adults,  and  hence  the  treatment  indicated  in  the  first  instance  was 
the  use  of  galvanism  and  cold  water  applications.  But  further  experience  and 
long-continued  observations  are  needed  to  clear  up  the  course  and  nature  of  these 
cases. — London  Medical  Record,  March  15,  1878. 


1878.] 


Medicine. 


255 


Treatment  of  Rheumatic  Facial  Paralysis  by  Galvanism. 
Dr.  J.  Mascarel  (Bordeaux  Mtdical,  September  18,  1877)  alleges  that  lie 
obtains  much  success  from  the  following  method  of  treating  rheumatic  paralysis 
of  the  facial  nerve.  On  the  first  day  he  introduces  a  platinum  needle,  a  centi- 
metre or  a  centimetre  and  a  half  (T45ths  or  T6oths  of  an  inch)  in  the  direction  of 
the  stylo-mastoid  foramen,  towards  the  exit  of  the  facial  nerve  from  the  cranium. 
A  second  platinum  needle  is  placed  horizontally  in  front  of  the  orbit  on  the  para- 
lyzed side,  in  the  superior  fibres  of  the  orbicularis  palpebrarum  ;  the  needles  are 
then  connected  with  the  poles  of  a  battery  of  the  desired  intensity,  and  an  inter- 
rupted current  passed  during  twelve,  eighteen,  or  twenty  minutes.  Violent  con- 
tractions are  caused  by  this  plan,  almost  convulsive  in  the  orbicularis  palpebrarum, 
and  sometimes  the  eyelids  are  closed  at  the  first  sitting.  The  second  day,  this 
operation  is  repeated  with  the  palpebral  needle  below  the  eye.  On  the  third, 
fourth,  fifth,  and  sixth  days  the  facial  needle  is  successively  introduced  into  those 
muscles  of  the  face  which  prove  most  refractory  ;  the  other  needle  is  always  kept 
near  the  stylo-mastoid  foramen.  After  the  seventh  or  eighth  day  of  this  treat- 
ment the  paralysis  had  disappeared  in  a  dozen  successive  cases. — London  Med. 
Record,  May  15,  1878. 

Chloral  Hydrate  in  Laryngismus  Stridulus. 

Mr.  William  Stewart,  Hon.  Surgeon,  Beckett  Hospital  and  Dispensary, 
Barnsley,  states  (Lancet,  May  25,  1878)  that  in  cases  of  laryngismus  stridulus  he 
has  found  chloral  to  be  the  remedy  par  excellence.  Soon  after  commencing  its 
use  the  laryngeal  spasm  begins  to  recur  less  frequently,  and  the  attacks  become 
slighter  and  of  shorter  duration,  until  at  the  end  of  two  or  three  weeks  the  disease 
finally  disappears  altogether. 

With  regard  to  the  dose.  For  children  six  months  old,  two  grains  of  the  drug 
may  be  administered  three  times  a  day,  increased  to  two  grains  and  a  half  at 
twelve  months,  and  to  three  grains  at  two  years.  In  these  doses  he  never  ob- 
served any  unpleasant  symptom  or  disagreeable  effects  from  its  use. 

With  regard  to  its  mode  of  action,  it  appears  to  him  to  be  beneficial  by  blunt- 
ing the  highly  nervous  excitability  which  exists  in  children  of  this  age,  and  by 
thus  calming  for  a  time  the  irritability  of  the  nerve  involved  in  producing  the 
spasm  a  cure  is  at  length  effected.  To  meet  the  treatment  of  the  constitutional 
cachexia,  he  has  administered  powders  of  the  phosphate  of  lime  night  and  morn- 
ing, or  a  few  drops  of  the  syrup  of  the  hypophosphite  of  lime  in  order  to  assist 
the  development  of  the  teeth,  and  to  promote  the  growth  of  bone  generally,  and 
at  the  same  time  he  has  prescribed  dietetic,  hygienic,  and  other  remedial  agents 
to  remove  as  far  as  possible  permanently  the  constitutional  causes  without  which 
the  disease  would  probably  never  have  had  an  existence. 

Form  of  Submucous  Laryngeal  Hemorrhage  not  hitherto  Observed. 
In  the  Berliner  Klinische  Wochenschrift  for  April  1st,  Dr.  Sommerbrodt 
remarks,  that  hemorrhage  in  cases  of  acute  laryngitis  is  not  rare  ;  such  cases  being 
described  by  Dr.  Frankel  as  laryngitis  hemorrhagica.  But  the  following  case  is 
unique.  A  girl,  twenty  years  of  age,  presented  herself  in  January  last,  with  the 
statement  that,  about  two  hours  before,  she  had,  while  eating,  swallowed  some- 
thing which,  she  said,  had  stuck  in  her  throat,  causing  a  pricking  pain  about  the 
larynx  and  much  discomfort,  and  that  all  efforts  to  remove  it,  by  swallowing 
bread,  etc.,  had  been  futile.  On  examination,  there  was  found  projecting  into 
the  pharynx  from  the  posterior  laryngeal  wall  a  dark,  rounded  body,  of  the  size 
of  a  cherry-stone,  while  all  surrounding  parts  were  perfectly  normal.    It  was  soft 


256 


Progress  of  the  Medical  Sciences. 


[July 


and  firmly  adherent  to  the  inter-arytenoid  space,  and  its  manipulation  under  ex- 
amination caused  no  pain.  On  opening  it  with  a  bistoury  a  quantity  of  dark 
blood  flowed  out,  and  the  swelling  disappeared.  It  was,  therefore,  a  submucous 
blood  tumour  of  the  posterior  laryngeal  wall,  simulating  a  foreign  body.  Its 
origin  was  due,  probably,  to  bruising  of  the  mucous  membrane  through  swallow- 
ing a  hard  morsel.  Similar  cases  sometimes  occur  of  blood-tumours  of  the  buccal 
mucous  membrane  through  bruising  by  the  teeth. — London  Med.  Record,  May 
15,  1878. 

Exophthalmic  Goitre  Cured  by  Galvanization  of  the  Sympathetic. 
Dr.  Ancona  (Giornale  Veneto  del/e  Scienze  Mediche)  relates  the  case  of  a 
young  girl,  aged  19,  of  habitually  bad  health,  who  suffered  from  exophthalmos 
and  goitre.  She  was  emaciated,  weak,  suffered  from  diarrhoea  and  frequent 
flushings  of  the  face ;  was  irritable  and  capricious,  and  unceasingly  dyspeptic. 
Dr.  Ancona  proposed  galvanization  of  the  first  cervical  ganglia  of  the  sympa- 
thetic. The  poles  of  a  Stohrer's  battery  were  applied  on  each  side  of  the  neck, 
behind  the  angle  of  the  jaw,  pressing  backwards  the  sterno-mastoid  muscles.  A 
current  often  elements  was  passed  for  a  time  varying  from  three  to  five  minutes. 
After  a  few  days,  the  circuit  was  frequently  interrupted.  The  physiological 
effects  observed  were  the  following :  dilatation  of  the  pupil  each  time  the  current 
was  closed,  more  marked  on  the  side  of  the  negative  pole ;  slight  contractions  of 
the  sterno-mastoid  ;  scalorrhoea,  with  a  taste  of  copper  in  the  mouth  ;  sometimes 
giddiness.  At  the  end  of  five  months,  a  hundred  electrizations  had  been  applied 
and  very  well  borne.  Arsenical  treatment  was  added.  From  the  beginning  of 
the  application  of  electricity,  there  was  notable  amelioration,  and  at  the  end  of 
five  months  the  state  of  the  patient  was  very  satisfactory.  Her  weight  had  in- 
creased by  30  lbs.  Her  face  and  mucous  membrane  resumed  their  normal  col- 
our ;  her  eyelids  regained  their  mobility;  the  thyroid  gland  diminished  in 
volume  ;  the  arterial  pulsation  ceased  to  be  visible  ;  the  pulse  of  the  heart  became 
regular ;  the  pulse  fell ;  menstruation  became  regular ;  digestion  was  restored  ; 
and  strength  returned. — British  Med.  Journal,  June  1,  1878. 

Treatment  of  Asthma  by  Subcutaneous  Injection  of  Arsenic. 
Dr.  Martelli  reports,  in  the  Gazzetta  Medica  Italiana  (Allgemeine  Med. 
Central.  Zeitinuj,  No.  2,  1878),  the  case  of  a  man  aged  30,  who  had  suffered 
from  repeated  attacks  of  asthma,  which  were  not  relieved  by  various  methods  of 
treatment,  including  subcutaneous  injection  of  strong  solutions  of  morphia.  Dr. 
Martelli  used  subcutaneous  injections  of  Fowler's  solution  of  arsenic  (one  part  to 
two  of  water).  Two  or  three  syringefuls  were  injected  through  the  same  punc- 
ture. The  effect  was  remarkable ;  the  paroxysms  at  once  ceased.  After  two 
drachms  of  the  arsenical  solution  had  been  used,  the  disorder  quite  disappeared, 
and  the  patient's  health  improved  greatly.  Later,  there  was  a  return  of  the 
asthma,  which  was  subdued  by  two  injections  of  the  solution.  The  injections 
were  not  attended  by  any  troublesome  results,  local  or  general,  beyond  pain  in 
the  arm  of  very  short  duration. — London  Med.  Record,  May  15,  1878. 

Morbid  Local  Temperature  in  Pleurisy. 
Prof.  Peter,  in  a  communication  to  the  Academie  de  Medecine  (Bulletin. 
April  30),  states  that  he  is  desirous  of  recording  the  results  of  a  long  series  of 
investigations  on  morbid  local  temperatures  in  which  he  has  been  engaged.  His 
first  communication  relates  to  the  temperature  of  the  thorax  in  acute  pleurisy, 
and  the  variations  which  this  undergoes,  according  to  certain  determinate  condi- 


1878.] 


Medicine. 


257 


tions,  in  relation  to  the  normal  mean  temperature  and  the  parietal  temperature 
of  the  health y  side.  This  is  not,  he  says,  a  piece  of  mere  scientific  curiosity,  but 
has  immediate  useful  clinical  applications,  enabling  us,  among  other  things,  to 
establish  a  diagnosis  in  doubtful  cases  of  commencing  pulmonary  tubercu- 
lization. 

The  results  of  his  investigations  show:  1.  On  the  side  of  the  pleurisy  the 
parietal  temperature  is  always  greater  than  the  mean  temperature  (35. 8°  C.)  ; 
this  morbid  excess,  or  local  hyperthermy,  amounting  to  from  0.5°  to  2°  and  more, 
since  the  looal  temperature  may  reach  38°,  39°,  or  even  40°.  2.  The  elevation 
of  temperature  increases  with  the  effusion,  i.  e.,  this  increase  corresponds  to  the 
period  of  secretory  activity  of  the  inflamed  pleura,  and  may  amount  to  2.5°  or  3°. 

3.  This  temperature  decreases  as  soon  as  the  level  of  the  effusion  remains  sta- 
tionary, that  is,  when  it  ceases  to  be  produced.  But,  generally,  the  parietal 
temperature  still  exceeds  that  of  the  unaffected  side  by  from  0.5°  to  1.5°. 

4.  Xot  only  does  the  pleurisy  raise  the  temperature  on  the  affected  side,  but  also 
that  on  the  opposite  side ;  but  the  temperature  is  always  higher  (from  some 
tenths  of  a  degree  to  one  degree  or  more)  at  the  former  than  the  latter.  5.  The 
parietal  temperature  becomes  gradually  lower  as  the  effusion  is  spontaneously 
absorbed,  always,  however,  remaining  higher  (generally  by  some  tenths  of  a 
degree)  than  on  the  sound  side,  such  increase  persisting  for  a  considerable  time. 
Such  persistence  is  not  to  be  neglected,  as  it  indicates  the  continuance  of  the 
anatomical  conditions  which  give  rise  to  the  effusion,  and  the  possibility  of  a  re- 
lapse. G.  In  cases  of  pleurisy  without  effusion  (as  diaphragmatic  pleurisy,  for 
example)  the  local  hyperthermy  is  less- high,  and  the  normal  temperature  returns 
more  rapidly.  7.  Perhaps  one  of  the  most  interesting  facts  is  that  the  absolute 
elevation  of  the  local  temperature  of  the  bad  side  is  more  considerable  than  the 
absolute  elevation  of  the  axillary  temperature,  although  the  axillary  thermic 
figure  may  be  higher  than  the  parietal  thermic  figure.  This  local  hyperthermy 
precedes  the  axillary  hyperthermy — two  circumstances  which  demonstrate  the 
predominant  influence  of  the  pleuritic  morbid  process  over  the  general  condition, 
or  at  all  events  over  the  general  temperature.  8.  When  the  effused  fluid  is 
evacuated — that  is,  the  cavity  of  the  pleura  emptied — an  unexpected  phenomenon 
is  immediately  produced ;  the  elevation  of  the  parietal  temperature  on  the  punc- 
tured side  ;  and  one  of  two  circumstances  may  take  place.  («)  If  the  effusion  is 
not  reproduced,  the  temperature  (which  before  the  puncture  was  higher  than 
normal  and  higher  than  on  the  sound  side)  may  rise  some  tenths  of  a  degree  still 
higher.  But  this  is  the  case  only  for  from  twenty-four  to  forty-eight  hours,  after 
which  the  parietal  temperature  sinks  first  to  the  figure  it  stood  at  before  the  ope- 
ration, and  then  continues  to  decrease  till  it  reaches  the  normal  figure,  35.8°. 
(b)  If  the  secretion  is  reproduced  and  then  absorbed  again,  during  the  period  of 
renewed  secretion,  the  local  temperature  rises  very  notably,  as  much  as  1°  some 
hours  after  the  puncture.  It  hovers  about  this  hyperthermy  for  some  days,  then 
decreases  under  the  influence  of  medicinal  agents,  returns  to  the  figure  it  stood 
at  prior  to  the  puncture,  and  finally  returns  to  the  normal  state.  It  is  remark- 
able that,  both  as  regards  the  elevation  and  depression  of  the  temperature,  the 
parietal  temperature  always  precedes  the  axillary  temperature,  the  local  malady 
seeming  still  to  govern  the  general  temperature.  "When  for  the  reproduced  effu- 
sion, puncture  requires  to  be  again  resorted  to,  we  have  local  preceding  general 
hyperthermy.  and  then  a  stationary  condition  of  the  local  temperature  during  the 
effusion.  After  a  new  puncture  the  same  thermic  and  secretory  phenomena  are 
reproduced. — Med.  Times  and  Gaz.,  June  1,  1878. 

No.  CLI  July  1878.  17 


258 


Progress  of  the  Medical  Sciences. 


[July 


Franck  and  Bellouard  on  the  Diagnostic  Value  of  the  Radial  Pulse  in  Innominate 

Aneurism. 

The  radial  pulse  below  an  aneurismal  tumour  generally  presents  two  peculiari- 
ties of  great  diagnostic  value :  firstly,  diminished  fulness ;  secondly,  a  delay  in 
point  of  time  as  compared  with  the  pulse  of  the  opposite  wrist.  By  reason  of 
its  greater  constancy,  the  second  of  these,  the  delay,  is  by  far  the  more  import- 
ant of  the  two.  A  case  of  innominate  aneurism  examined  by  Dr.  Panas  shows 
of  how  little  value  is  diminished  fulness  regarded  as  a  symptom,  for  the  radial 
pulse  below  the  aneurism  showed  considerable  fulness,  whereas  the  left  pulse  was 
so  small  as  hardly  to  be  appreciable  by  the  sphygmograph.  M.  Bucquoy  men- 
tions a  similar  case.  A  careful  examination  of  the  circulatory  disturbances  of 
the  arm,  face,  and  fundus  of  the  right  eye  led  these  two  observers  to  attribute 
the  increase  of  fulness,  in  the  instances  just  alluded  to,  to  vaso-motor  paralysis 
consequent  upon  functional  derangement  of  the  first  thoracic  ganglion  of  the  sym- 
pathetic, due  to  compression  by  the  largely  developed  aneurismal  tumour.  In  a 
patient  with  innominate  aneurism  mentioned  byM.  Bellouard,  a  slight  sinking  in 
of  the  globe  of  the  right  eye,  a  decided  diminution  in  the  palpebral  orifice,  and 
a  well-marked  excavation  of  the  optic  disk  were  observable,  and  were  known  to 
have  been  present  for  a  long  time.  The  field  of  vision  of  the  affected  eye  was 
reduced  to  nearly  zero  on  the  nasal  side,  which  confirmed  the  oplithalmoscopical 
appearances  of  the  disk.  There  was  also  present  a  marked  4liminutibn  in  the 
acuteness  of  vision  of  the  right  eye  as  compared  with  the  left. 

This  case  offers  an  excellent  opportunity  for  studying  the  relations  existing  be- 
tween paralysis  of  the  sympathetic,  nutritive  disturbances  of  the  fundus  of  the 
eye,  and  partial  atrophy  of  the  papilla  entailing  diminution  in  the  field  and  in 
the  acuteness  of  vision  ;  for  there  can  be  no  doubt  that  in  this  case  the  ascending 
sympathetic  filaments  from  the  first  thoracic  and  inferior  cervical  ganglia  were 
paralyzed.  Those  from  the  first  thoracic  ganglion  supplying  the  vessels  of  the 
upper  extremity  being  similarly  affected,  the  fulness  of  the  radial  pulse  is  ac- 
counted for. 

The  sphygmographic  tracings  of  the  right  pulse  shown  by  M.  Franck  display 
a  suddenness  of  impulse  altogether  absent  in  those  of  the  left  side.  In  conse- 
quence of  this  energetic  circulation  in  the  right  upper  extremity,  and  contrary  to 
what  one  generally  observes  in  aneurism,  there  was  a,n  elevation  of  1°  F.  on  the 
affected  side,  of  which  the  patient  was  herself  perfectly  conscious. 

It  may  therefore  be  concluded  that  the  smallness  of  pulse  and  fall  of  tempera- 
ture below  an  aneurism  may  be  replaced  by  inverse  symptoms,  provided  the  aneu- 
rismal tumour  compresses  and  paralyzes  the  sympathetic  ganglia  or  filaments 
concerned  in  that  region.  Again,  symptoms  of  either  kind  may  be  altogether 
absent ;  at  any  rate  their  uncertainty  and  their  dependence  on  adventitious  con- 
ditions should  render  them  of  second-rate  importance.  Of  first-rate  importance 
is  the  delay  of  pulse  which  no  nervous  influence  can  suppress,  though  the  peri- 
pheral vascular  dilatation  and  consequent  easy  flow  of  blood  in  the  extremity  tend 
to  render  it  less  distinct.  By  means  of  an  apparatus  devised  by  M.  Franck,  he 
shows  that  during  the  expansion  of  the  tumour  the  pulse  of  the  right  hand  is 
delayed  a  third  after  that  of  the  left,  in  the  case  above  alluded  to. 

Though  the  absolute  amount  of  delay  varies  with  circumstances,  and  is  neces- 
sarily influenced  by  all  kLids  of  conditions,  yet  its  constancy,  the  fact  that  there 
always  is  delay,  however  slight,  renders  this  symptom  of  the  very  highest  diag- 
nostic value  in  cases  of  suspected  innominate  aneurism. — London  Med.  Record, 
March  15,  1878. 


1878.] 


Medicine. 


259 


Case  of  Hepatic  Abscess  Opening  into  the  Lung:  Successful  Treatment 
by  Carbolic  Acid. 

Dr.  P.  Carrescia  relates,  in  11  Morgagni  for  December,  1877,  the  case  of  a 
man  who,  having  suffered  for  a  long  time  from  a  malarial  affection,  was  suddenly 
attacked  with  vomiting  of  pus,  due,  without  doubt,  to  the  bursting  into  the  bronchi 
of  an  abscess  of  the  liver.  In  these  circumstances,  Dr.  Carrescia,  remembering 
the  remarkably  beneficial  effects  of  carbolic  acid  in  suppurative  pneumonia,  was 
led  to  employ  it  as  a  disinfectant  and  modifying  agent  on  the  abscess.  After  six- 
teen days  of  treatment  by  the  daily  administration  of  from  15  to  40  drops  of  a 
solution  of  carbolic  acid  [of  what  strength?],  the  patient  gradually  completely 
recovered.  The  author  does  not  overlook  the  fact  that  abscess  of  the  liver  may 
lieal  spontaneously  ;  but,  in  the  present  case,  the  rapid  diminution  of  the  pus,  the 
absence  of  pain,  and  the  improvement  of  nutrition,  appear  to  him  to  render  the 
effect  of  the  treatment  undeniable.  He  concludes,  therefore,  that  the  internal 
use  of  carbolic  acid  in  abscess  of  the  liver  may  exercise  some  special  action  such  as 
lias  already  been  described  in  suppurative  pneumonia,  and  expresses  the  desire 
that  the  value  of  the  treatment  may  be  tested  by  clinical  observation. — London 
Med.  Record,  May  15,  1878. 

Diabetes  Insipidus  rapidly  Cured  by  Ergot. 

A  recent  number  of  the  France  MMicale  contains  an  account  of  a  very  severe 
case  of  polyuria  which  rapidly  yielded  to  the  internal  administration  of  ergot  of 
rye.  The  patient  was  a  man,  aBt.  46,  and  the  symptoms  followed  a  prolonged 
immersion  in  the  sea.  They  were  ushered  in  by  giddiness,  pain  in  the  head,  and 
nausea ;  to  these  were  soon  added  profuse  perspiration,  frequent  desire  to  pass 
urine,  thirst,  and  increased  appetite.  The  daily  quantity  of  urine  rose  to  350 
ounces,  of  a  sp.  gr.  of  1017.  Neither  albumen  nor  sugar  was  present.  The 
quantity  was  reduced  by  atropine,  but  the  other  effects  of  this  remedy  were  very 
disagreeable  to  the  patient.  Ergot  of  rye  was  then  given,  in  doses  of  seventy-five 
grains  daily,  and  in  nine  days  the  quantity  of  urine  was  reduced  from  240  to  70 
ounces.  The  other  symptoms  also  disappeared,  and  the  patient  soon  regained  his 
normal  condition. — Med.  Examiner,  June  6,  1878. 

Treatment  of  Obstinate  Sciatica,  by  Subcutaneous  Injections  of  Nitrate  of  Silver. 

Dr.  Auguste  Dureau  has  had  the  opportunity  of  observing,  in  MM.  Dama- 
schino  and  Gerin-Roze's  wards,  the  generally  favourable  results  obtained  in  the 
treatment  of  obstinate  sciatica  by  the  method  of  Dr.  Luton,  of  Rheims.  M. 
Dureau  (Ttese  de  Paris,  Feb.  27,  1877)  recommends  that  the  end  of  the  canula 
of  the  subcutaneous  injection-syringe  should  be  inserted  deep  enough  to  go  through 
the  dermis.  The  injection  has  always  been  made  in  the  nates  at  the  point  where 
the  sciatic  nerve  emerges.  M.  Dureau  furnishes  the  following  indications  as  to 
the  preparation  and  quantity  of  nitrate  of  silver  employed.  Dr.  Damaschino 
always  employs  a  twenty-five  per  cent,  solution  in  doses  of  five  drops,  and  it  has 
always  yielded  good  results.  Dr.  Luton  varies  the  strength  and  the  quantity  of 
his  solution,  sometimes  using  from  twenty  to  twenty-four  drops  of  a  ten  per  cent, 
solution,  sometimes  the  same  quantity  of  a  five  per  cent,  solution.  The  solution 
employed  by  Dr.  Bertin,  of  Gray,  is  a  five  per  cent,  one,  and  the  number  of  drops 
injected  varies  from  15  to  20  or  25  drops.  Dr.  Gerin-Roze  uses  the  fifteen  per 
cent,  solution  in  doses  of  15  drops.  Out  of  twelve  cases,  this  physician  has  had 
some  cures,  some  cases  of  improvement,  and  some  which  remain  in  statu  quo ;  he 
has  never,  however,  seen  any  unpleasant  results.   M.  Dureau  comes  to  the  follow- 


260  Progress  of  the  Medical  Sciences.  [July 


ing  conclusions :  1.  The  injections  of  nitrate  of  silver  are  recommended  for  old 
and  obstinate  neuralgia.  2.  Irritation  from  injections  into  the  depth  of  the  tissues 
is  not  to  be  feared,  as  is  generally  supposed.  3.  The  mode  of  applying  the  drug 
allows  the  affected  point  to  be  reached,  and  gives  so  much  the  more  certainty  to 
its  action.  4.  Cure  or  improvement  is  very  rapid.  5.  Finally,  this  method  is 
less  alarming  and  much  more  efficacious  than  the  hot  iron. — Lond.  Med.  Record, 
March  15,  1878. 

Coloured  Exudation  in  Eczema. 
Dr.  Lindsay  gives,  in  the  Medical  Times  and  Gazette,  March  9,  1878,  pp. 
247,  273,  details  of  a  case  where  the  dressings  from  an  eczematous  leg  were  stained 
blue,  and  occasionally  green.  The  patient,  aged  35,  a  tall,  handsome,  athletic 
man,  had  been  subject  to  periodic  attacks  of  eczema  ;  and  during  one  of  his  usual 
attacks,  wherein  the  legs  were  affected,  and  which  attack  extended  over  several 
weeks,  the  various  dressings  applied  to  the  leg,  as  well  as  the  drawers,  stockings, 
or  other  articles  of  clothing  that  became  fouled,  all  assumed  various  shades  of  blue, 
sometimes  of  green,  just  as  though  they  had  been  purposely  stained  with  a  solu- 
tion of  sulphate  of  copper  or  of  indigo.  That  no  deceit  was  practised  was  certain. 
No  medicines  were  being  administered  internally  at  the  time,  and  no  local  appli- 
cations but  simple  water-dressings  were  used.  The  urine  was  normal  and  free 
from  colour.  He  was  the  subject  of  a  certain  degree  of  mental  imbecility,  the 
result  of  "  cram"  at  sixteen  years  of  age.  Dr.  Lindsay  brought  the  case  before 
the  notice  of  Drs.  M'Call  Anderson  and  Peel  Ritchie.  To  the  former  it  was  new  ; 
the  latter  gentleman  had  seen  similar  cases,  and  believed  it  might  be  due  to  renal 
inadequacy.  In  the  concluding  part  of  his  interesting  paper.  Dr.  Lindsay  gives 
a  good  deal  of  useful  information  upon  the  literature  of  the  pigmentary  exudations 
in  the  different  secretions  of  the  body,  viz.,  pus,  urine,  sweat,  serous  effusions, 
etc. — London  Med.  Record,  May  15,  1878. 

Urticaria  following  the  Administration  of  Salicylate  of  Soda. 

In  the  Aerztliclies  Tntelligenz-Blatt  for  April  9,  Dr.  Heinlein,  of  Erlangen, 
communicates  the  following  case  which  occurred  during  the  last  winter. 

C.  K.,  a  house-painter,  aged  45,  had  a  severe  attack  of  articular  rheumatism  in 
1853,  from  which  herecovered  slowly.  Since  then  he  had  several  further  attacks, 
and  while  suffering  from  the  last  was  admitted  to  the  polyclinic,  at  Erlangen,  on 
November  17,  187  7.  He  presented  the  usual  symptoms  of  rheumatic  inflamma- 
tion in  the  elbow  and  knee-joints.  The  pulse  was  intermittent  throughout  the 
course  of  the  case,  raising  the  suspicion  of  a  fatty  heart,  which  was  further  indi- 
cated by  the  pasty  appearance  of  the  patient,  and  by  his  acknowledged  addiction 
to  alcoholic  liquors. 

During  the  first  ten  days,  salicylate  of  soda  was  given  in  hourly  doses  of  7  7 
grains  (0.5  grammes)  without  any  effect.  Thereupon  the  dose  was  increased  to 
60  grains  (4.0  grammes)  with  the  following  result.  Soon  after  this  first  dose  was 
given,  there  came  on  intense  tingling  and  itching  of  the  skin.  The  left  side  of 
the  face,  the  lower  extremities,  and  the  right  side  of  the  chest  were  diffuse]  v 
reddened,  while  both  eyelids,  the  upper  lip,  and  a  great  part  of  the  legs  were 
slightly  oedeniatous.  The  pulse  stood  at  90°,  temperature  at  101.8°  F.,  and  the 
urine  was  slightly  albuminous.  At  the  same  time  all  pain  in  the  affected  joints 
had  vanished,  and  they  could  be  freely  moved  about,  By  the  next  morning  the 
redness  bad  disappeared,  and  the  pulse  and  temperature  had  fallen  respective! y 
to  80°  and  100°  F.  In  order  to  ascertain  how  far  these  symptoms  were  the  re- 
sult of  the  treatment,  it  was  determined  to  repeat  the  dose  at  the  next  opportunity. 


1878.] 


Surgery. 


261 


The  patient  continued  free  from  pain  for  the  next  three  days,  but  on  the  fourth 
day  the  articular  pains  returned  with  such  severity,  that  the  patient  himself 
begged  for  "  the  large  powder."  Sixty  grains  (4.0  grammes)  of  salicylate  of  soda 
were  given  ;  after  fifteen  minutes,  severe  burning  pain  in  the  frontal  integument 
supervened,  and  five  minutes  later  strong  itching  on  the  back  of  the  right  hand. 
In  half  an  hour  a  marked  eruption  of  urticaria  was  established  over  the  greater 
part  of  the  body,  especially  the  legs  and  abdomen,  with  some  cedematous  swelling 
of  the  arms,  eyelids,  etc.  This  disturbance  moderated  in  the  course  of  two  or 
three  hours,  and  had  completely  subsided  the  next  day.  Subsequently,  several 
-mailer  doses  were  administered  without  producing  any  of  the  above  effects,  and 
the  patient  recovered.  After  his  recovery  the  patient  consented  once  more  to 
take  the  larger  dose,  and  the  result  was  precisely  the  same  as  before.  Hence  it 
is  evident  that  salicylate  of  soda  must  be  classed  with  those  drugs — cubebs,  co- 
paiba, santonin,  turpentine,  valerian — the  administration  of  which  is  sometimes 
attended  by  urticaria. — London  Med.  Record,  May  15,  1878. 


SURGERY. 

Morbid  Anatomy  of  Tetanus. 
Dr.  E.  Aufrecht,  of  Magdeburg  {Deutsche  Medicin.  Wochenschrift,  April  8), 
gives  an  excellent  account  of  the  morbid  appearances  found  in  the  spinal  cord  of 
a  case  of  tetanus.  The  patient,  a  labourer,  aged  41,  got  a  compound  dislocation 
of  the  thumb,  which  was  treated  by  Lister's  method.  Eight  days  afterwards, 
spasm  of  the  muscles  of  the  jaw  and  neck  set  in,  for  which  Dr.  Hagedorn 
stretched  the  median  nerve,  but  with  no  good  result,  as  the  patient  died  two  days 
after  the  first  appearance  of  the  tetanic  symptoms.  At  the  post-mortem  exami- 
nation, the  sac  of  the  spinal  dura  mater  contained  a  considerable  quantity  of 
serum,  and  the  cord,  both  gray  and  white  matter,  was  obviously  hypersemic. 
After  hardening  for  three  months  in  a  solution  of  bichromate  of  potash,  which 
was  changed  every  day  or  every  second  day,  sections  were  made  and  carefully 
examined  with  the  microscope.  Throughout  the  cord,  the  vessels  were  found 
distended  with  red  blood-corpuscles;  this  hyperaemia  involved  arteries,  veins, 
and  capillaries,  as  was  proved  by  careful  isolation.  Around  the  larger  vessels, 
especially  in  the  lumbar  region,  there  were  found  masses  of  a  hyaline-looking  sub- 
stance, which  appeared  either  dull  or  with  short  bright  transverse  striation.  This 
material  adhered  to  the  adventitia,  even  when  the  vessels  were  isolated.  He  is 
inclined  to  regard  this  material  as  fibrin,  but  is  bound  to  point  out  that  it  was 
present  also  in  the  cavity  of  the  central  canal.  More  frequently,  dark  granules 
of  pigment  and  fatty-looking  molecules  were  present  in  the  adventitia.  In  the 
white  substance,  he  found  many  granules  of  pigment,  etc.,  and  many  of  the 
nerve-fibres  had  fine  granules  in  their  medullary  sheaths,  which  gave  these  latter 
a  dusty  appearance.  The  most  marked  changes  were  found  in  the  cells,  those  of 
the  cervical  region  having  the  lesion  most  pronounced,  while,  on  passing  down 
the  cord  to  the  lumbar  region,  the  departure  from  the  normal  became  less  and 
less,  although  even  in  the  latter  region  the  morbid  appearances  were  still  mani- 
fest. These  alterations  were  diminution  in  the  size  of  the  cells,  increase  of  pig- 
ment, loss  of  their  processes,  disappearance  of  nuclei  and  nucleoli,  the  cells 
becoming  of  a  diffuse  yellow  colour  and  containing  refractile  drops,  or  looking 
like  structureless  yellow  lumps.  The  cells  of  the  anterior  horns  of  the  lumbar 
region  were  quite  normal,  except  perhaps  a  slight  excess  of  pigmentation ;  those 


202 


Progress  of  the  Medical  Sciences. 


[July 


of  the  posterior  horns  -were  in  various  stages  of  degeneration.  In  the  cervical 
region,  not  one  single  normal  cell  could  be  seen ;  they  were  represented  by  rust- 
coloured  lumps  without  nuclei,  nucleoli,  or  processes.  In  addition  to  the  changes 
in  the  cells  themselves,  the  gray  matter  contained  many  fine  granules  and  coarser 
angular  coloured  grains,  which  quite  resembled  the  pigment-grains  of  the  cells. 
These  were  grouped  especially  round  the  central  canal,  which  seemed  wider  in 
the  cervical  region.  The  epithelium  of  the  central  canal  was  normal,  but  the 
lumen  was  in  many  places  nan-owed  ;  an  appearance,  he  believes,  not  due  to  his 
mode  of  preparation.  There  were  also  around  the  central  canal  many  globular 
bodies  without  any  contour,  which  resembled  oil-trlobules.  Dr.  Aufrecht  com- 
pares these  appearances  with  those  described  byLockhart  Clarke,  W.  H.  Dickin- 
son, and  Tyson.  He  agrees  with  Lockhart  Clarke  in  describing  the  change  in 
the  cells  as  granular  degeneration ;  but  differs  from  him  in  so  far  as  he  is  rather 
inclined  to  regard  their  cell-changes  as  primary ;  in  fact,  as  a  parenchymatous 
inflammation  analogous  to  what  takes  place  in  the  cells  of  the  liver  and  of  the 
sympathetic  ganglion,  and  not  as  secondary  to  the  vascular  disturbance.  He  is 
by  no  means  sure  that  the  masses  around  the  vessels  were  really  fibrin,  but  is 
disposed  to  consider  them  colloid.  This  part  of  the  paper  seems  rather  weak, 
and  we  are  by  no  means  convinced  by  his  arguments;  for  instance,  he  contends 
that,  as  the  hyperamiia  extended  for  the  whole  length  of  the  cord,  while  the 
changes  in  the  parenchyma  diminished  in  their  intensity  in  passing  downwards, 
therefore  there  was  no  relation  between  the  two  ;  that  the  granules  were  not 
numerous  around  the  vessels ;  and  that  some  of  the  fibrin-looking  material  lay  in 
the  central  canal.  He  contends  that  there  is  nothing  characteristic  of  tetanus  in 
this  material,  as  Hayem  found  it  in  two  cases  of  acute  diffuse  central  myelitis. 
This  we  should  not  dispute,  as  we  rarely  expect  to  find  anything  characteristic  in 
the  nature  of  an  exudation.  Dr.  Aufrecht's  observations  are  an  important  addi- 
tion to  our  knowledge  of  the  morbid  changes  in  tetanus,  and  go  to  support  the 
view  that  the  lesion  consists  in  an  acute  diffuse  central  myelitis. — British  Med. 
Journal,  May  18,  1878. 

The  Union  of  Divided  Bloodvessels. 
The  union  of  divided  bloodvessels  has  been  carefully  studied  by  Pfitzer  in 
the  Institute  for  Pathological  Anatomy  at  Konigsberg.  The  process  was  investi- 
gated in  the  rabbit.  The  wound  was  found  to  be  first  closed  by  a  thrombus  con- 
taining abundant  cells — the  "  white  thrombus  "  of  Zahn.  In  about  twenty-four 
hours,  however,  hardly  any  cells  were  to  be  seen,  the  material  closing  the  wound 
consisting  then  only  of  a  homogeneous  structureless  mass  of  fibrin.  Two  days 
later,  the  endothelium  in  the  entire  circumference  of  the  vessel  was  swollen,  and 
on  the  third  day  connected  with  the  endothelium,  and  apparently  arising  from  it. 
a  single  layer  of  spindle-cells  lay  in  the  fibrinous  mass.  Beneath  the  swollen  en- 
dothelium, close  to  the  wound,  were  several  layers  of  irregular  cells,  very  different 
from  pus-corpuscles.  After  this  date,  the  wound  adjacent  to  the  lumen  of  the 
vessel  was  closed  by  this  layer  of  spindle-cells,  continuous  with  the  endothelium 
of  the  vessel.  Next,  cells  arise  in  connection  with  the  adventitia  of  the  vessel, 
at  first  round,  then  becoming  spindle-shaped,  and  ultimately  passing  into  cicatri- 
cial tissue-  Whether  these  are  developed  from  pre-existing  cells  or  from  cells 
which  have  wandered  out  of  the  vessel  is  left  uncertain.  They  become  connected 
with  the  spindle-cells  which  have  proceeded  from  the  endothelium  and  subendo- 
thelial  cell-layer.  Gradually  the  cells  are  transformed  into  tracts  of  tissue  of 
cicatricial  aspect,  and  in  eleven  days  only  such  tissue  is  to  be  seen  closing  the 
wound.  Thus  it  would  appear  that  a  double  process  takes  part  in  the  union.  On 
the  one  hand  there  is  a  proliferation  of  the  endothelium  of  the  vessel,  and  on  the 


1878.] 


Surgery. 


263 


other  an  inflammatory  growth  of  tissue  proceeding  from  the  divided  adventitia  of 
the  vessel.  The  participation  of  the  white  blood-corpuscles  in  the  process  appa- 
rently ceases  with  the  formation  of  the  provisional  plug. — Lancet,  May  18,  1878. 

The  Application  of  the  Antiseptic  Method  in  Cases  where  Sepsis  is  already 

present. 

Dr.  Konig  (Gottingen)  read  a  paper  on  this  subject  at  the  late  congress  of  the 
Society  of  German  Surgeons.  If  Lister's  antiseptic  method,  intended  at  first 
only  for  the  treatment  of  clean  wounds,  obtain  a  lasting  value  in  surgery,  it  must 
soon  be  extended  to  cases  in  which  inflammation  and  sepsis  are  already  present ; 
and  in  this  respect  it  has  already  been  strikingly  proved  to  be  useful.  In  many 
cases  of  suppurative  inflammation  of  tendons,  the  necrosis  of  the  tendons  has  been 
prevented  by  making,  as  early  as  possible,  numerous  incisions  along  the  whole 
track  of  the  inflammation,  and  thoroughly  washing  and  rubbing  the  sheaths  of  the 
tendons  with  a  5  per  cent,  solution  of  carbolic  aeid  ;  after  which  drainage-tubes 
were  applied,  and  the  limb,  being  suspended,  was  irrigated  by  the  constant  drop- 
ping on  it  of  a  weak  solution  of  salicylic  aeid.  In,  recent  cases  of  empyema  it  was 
sufficient,  according  to  Dr.  Konig,  to  make  an  incision  at  the  most  dependent 
part,  and  resect  a  portion  of  rib,  and  then  to  wash  out  the  pleura  with  a  5  per  cent, 
solution  of  carbolic  aeid.  To  remove  the  secretion  which  re-accumulated,  a 
drainage-tube  was  applied,  the  body  being  placed  in  a  proper  position,  and  the 
part  was  dressed  antiseptically.  The  treatment  of  septic  wounds,  especially  those 
complicating  fractures,  by  means  of  powerful  disinfection,  with  division  and  re- 
moval of  the  destroyed  and  dead  parts,  was  illustrated  by  the  account  of  a  case  of 
compound  fracture  of  the  thigh  and  leg,  with  gangrenous  emphysema,  in  which 
life  was  preserved  by  amputation  and  the  observance  of  the  plan  above  men- 
tioned. Such  good  results,  however,  could  be  obtained  only  by  the  abundant  use 
of  carbolic  acid,  as  a  result  of  which  he  had  now  and  then  met  with  toxic  symp- 
toms, never,  however,  ending  in  death.  He  discarded  the  silk  protective,  and 
laid  gauze  direct  on  the  wound  or  ulcer,  in  order  to  better  obtain  absorption  and 
consequent  disinfection  of  the  secretions. 

Dr.  Bardeleben  (Berlin)  said  that  since  1872  he  had  used  carbolic  acid 
irrigation  with  the  best  results,  in  cases  of  the  kind  described  by  Dr.  Konig.  He 
had  never  seen  special  toxic  symptoms,  even  after  prolonged  irrigation  with  car- 
bolic acid,  although  most  of  his  patients  passed  dark-coloured  urine.  A  solution 
of  thymol  (1  part  in  1000,  with  the  addition  of  some  alcohol)  had  already  been 
used  in  his  wards  in  1875,  but  had  been  given  up,  partly  on  account  of  the  sweetish 
smell  of  the  agent,  and  partly  because  it  attracted  swarms  of  flies.  A  renewed 
experience  of  thymol  during  the  past  year  had  taught  him  that  the  results 
obtained  by  it  did  not  surpass  those  of  a  1^  or  2  per  cent,  solution  of  carbolic  acid. 
If  thymol  had  not  the  unpleasant  paralyzing  action  on  granulations,  it  yet  did  not 
possess  the  higher  antiseptic  properties  of  unconcentrated  (e.  g.,  5  percent.)  car- 
bolic acid  solutions.  To  these,  as  well  as  to  solutions  of  chloride  of  .zinc  (both 
advocated  by  Lister),  surgeons  had  limited  themselves  in  the  disinfection  of  already 
putrid  parts  ;  and,  if  he  had  the  choice,  he  would  prefer  chloride  of  zinc,  as  its 
action  was  more  readily  limited  than  that  of  carbolic  acid. 

Dr.  Huter  (Greifswald)  had,  since  1869,  used  antiseptic  irrigation  with  good 
results  in  the  treatment  of  septic  wounds.  With  regard  to  carbolic  acid  poisoning, 
he  considered  that  strong  solutions  were  more  harmless  than  more  diluted  ones. 
Irrigation  with  carbolic  acid  was  of  special  benefit  in  intermuscular  phlegmon  of 
the  forearm,  especially  when  combined  with  numerous  buttonhole  incisions.  The 
success  obtained  by  the  use  of  carbolic  acid  irrigation  in  the  case  of  a  boy  whose 


264 


Progress  of  the  Medical  Sciences. 


[July 


abdominal  wall  was  injured  by  a  threshing-machine,  had  led  him  to  use  it  in  her- 
niotomy ;  the  result  being  that  he  no  longer  met  with  peritonitis  after  the  opera- 
tion, and  that  the  wound  healed  by  the  first  intention,  so  far  as  the  part  where 

the  drainage-tube  lay. 

Dr.  Kuster  (Berlin)  had  used  thymol  very  extensively  since  the  beginning  of 
the  present  year,  but  had  already  abandoned  it  as  an  aseptic,  on  account  of  its 
failure.  He  especially  ascribed  two  deaths  after  laparotomy  to  the  use  of  thymol. 
Whether  it  would  be  found  applicable  in  minor  operations  was  very  questionable, 
as  it  was  quite  as  expensive  for  dressings  as  chloride  of  zinc,  if  not  more  so. 

Dr.  Olshausex  (Halle)  agreed  with  the  observations  of  Dr.  Kuster  respect- 
ing the  use  of  thymol  in  cases  in  which  the  abdomen  was  opened. 

Dr.  Schede  agreed  with  the  previous  speakers  as  to  the  good  results  of  carbolic 
acid  irrigation  and  the  uncertainty  of  thymol.  Whatever  good  results  had  fol- 
lowed the  use  of  the  latter  were  perhaps  in  part  to  be  explained  by  the  fact  that, 
in  a  hospital  in  which  antiseptic  treatment  was  rigidly  carried  out,  all  recent  wounds 
showed  no  tendency  to  septicity.  He  had  lately  used  hyposulphite  of  soda  for 
antiseptic  irrigation ;  it  could  be  employed  in  a  5  per  cent,  solution,  or  even 
stronger,  in  any  quantity,  without  fear  of  toxic  action. 

Dr.  Koxig  said  that  there  was  a  misunderstanding  with  respect  to  the  use  of 
solution  of  carbolic  acid.  He  used , it  for  washing,  not  for  continued  irrigation  ; 
for  the  latter  he  used  salicylic  acid. 

Dr.  Thiersch  (Leipsic)  regretted  that  none  of  those  who  had  lately  praised 
thymol  were  present  to  speak  in  its  defence.  He  had  made  no  special  experi- 
ments with  it,  but  he  believed  that  the  difference  in  its  effects  depended  on  the 
time  during  which  and  the  manner  in  which  it  had  been  kept. 

Dr.  Bidder  declared  against  the  general  use  of  thymol,  which  he  recommended 
only  for  washing  out  the  cavities  in  empyema  and  abscess. 

Dr.  Wagner  had  seen  three  cases  of  empyema  in  which  complete  recovery 
took  place  in  eight  weeks,  after  treatment  by  double  incision,  the  use  of  a  drainage- 
tube,  repeated  washing  out  of  the  cavity,  and  gradual  removal  of  the  drainage- 
tube  after  eight  days,  until  only  a  small  piece  was  left  in  the  opening. 

Dr.  Schede  advocated  resection  of  one  or  more  ribs,  both  in  children  and  in 
adults.  In  this  way  the  diminution  of  the  cavity  in  empyema  was  more  rapid. 
He  would  use  salicylic  acid  or  thymol  for  washing  out,  only  when  symptoms  of 
poisoning  followed  the  use  of  carbolic  acid. 

Dr.  yon  Langexbeck  recommended  thymol  in  the  case  of  children,  although 
wounds  did  not  always  run  an  aseptic  course  under  its  use. — London  Med.  Record, 
May  15,  1878. 

Lymphadenoma  with  Retinal  Hemorrhages. 
M.  Chauvel  (Gazette  Hebdomadaire)  reports  a  characteristic  case  of  lympha- 
denoma.  A  custom-house  officer,  aged  41,  entered  hospital  on  account  of  a  tumour 
on  the  left  side  of  the  face.  He  had  always  been  healthy  :  there  was  no  history 
of  inherited  or  acquired  syphilis  or  other  disease.  Four  months  previously,  a 
small  painless  tumour  had  appeared  spontaneously  on  the  left  upper  eyelid.  It 
grew  very  rapidly,  and  began  to  be  painful.  On  entering  the  hospital,  the  patient 
had  infiltration  of  the  lymphatic  glands  of  both  sides  of  the  neck,  particularly  the 
glands  along  the  sterno-mastoid.  On  the  apex  of  the  tumour,  somewhat  above 
the  left  eyebrow,  was  a  reddish  sensitive  spot.  The  mucous  membrane  of  the  left 
cheek  presented  some  grayish  ulcere.  A  few  days  later,  diffuse  swelling  of  the 
face,  particularly  in  the  left  supra-orbital  region,  was  observed,  extending  some- 
what over  the  median  line  towards  the  right.  The  cheek  was  double  its  normal 
thickness  ;  the  swelling  faded  insensibly  into  the  surrounding  tissues.    There  were 


1878.] 


Surgery. 


265 


severe  neuralgic  pains  in  the  left  side  of  the  head,  earthy  coloration  of  the  skin, 
and  great  weakness.  Under  the  mucous  membrane  of  the  cheek,  hard  nodules 
could  be  observed,  with  greenish  gray  patches  about  the  upper  molar  teeth  ;  some 
days  later  the  right  cheek  became  swollen,  but  its  mucous  membrane  remained 
unchanged.  The  mouth  gave  a  fetid  odour.  The  patient  was  sleepless,  but 
snowed  no  disturbance  of  circulation,  respiration,  or  digestion.  Some  days  later 
the  patient  complained  of  a  black  spot  before  the  right  eye  (the  left  eye  was 
closed  by  the  tumour),  and  on  ophthalmoscopic  examination  several  hemorrhagic 
spots  could  be  observed  on  the  retina.  The  diagnosis  of  leukemic  retinitis  was 
made.  Excepting  the  glands  of  the  neck,  no  other  lymphatic  glands  were  ob- 
served to  be  enlarged.  The  spleen  was  only  slightly  enlarged.  The  blood  was 
not  examined.  The  patient  died  at  the  end  of  four  weeks.  The  post-mortem 
examination  showed  no  emaciation.  The  tumour  was  situated  chiefly  in  the  skin 
and  subcutaneous  cellular  tissue.  Section  showed  all  the  soft  tissues,  down  to  the 
healthy  periosteum,  changed  to  a  mottled  structure.  The  lymphatic  glands  pre- 
sented the  same  appearance,  which  was  shown  by  the  microscope  to  be  that  of  a 
characteristic  lymphatic  tumour.  The  spleen  was  somewhat  enlarged  ;  the  liver 
was  very  large  and  pale,  its  intralobular  capillaries  showing  a  large  proportion  of 
white  corpuscles  ;  there  was  much  albumen,  with  fibrinous  casts,  in  the  urine. — 
Land.  Med.  Record,  May  15,  1878. 

Removed  of  an  Enormous  Lipoma. 

Dr.  Wolfler,  one  of  Prof.  Billroth' s»assistants,  narrates  (Wiener  Med.  Woch., 
March  1G)  an  interesting  case  of  operation  for  a  large  lipoma  which  was  performed 
in  that  surgeon's  Klinik.  A  man  aged  seventy-one  having  entered  the  Klinik, 
August,  1877,  with  the  desire  that  a  large  tumour  should  be  removed,  the  ques- 
tion was  raised  whether,  in  a  person  of  his  age,  it  would  be  prudent  to  undertake 
such  an  operation.  The  great  substance  and  breadth  of  the  pedicle  of  the  tumour 
in  this  case  added  to  the  usually  unfavourable  view  taken  of  removing  very  large 
tumours.  On  the  other  hand  (1)  the  patient  ardently  desired  to  be  rid  of  his 
malady;  (2)  he  suffered  much  from  the  weight  of  the  tumour,  and  from  the  exco- 
riation, eczema,  and  ulcerations  which  its  friction  against  the  skin  of  the  back  in- 
duced; (3)  the  appearance  and  bodily  condition  of  the  patient  were  very  favour- 
able, in  spite  of  his  thirty  years'  endurance  of  his  calamity;  (4)  the  employment 
of  antiseptic  treatment  held  out  the  hope  that  the  danger  of  exposing  so  large  a 
surface  would  be  reduced  to  a  minimum.  The  tumour  hung  down  from  the 
shoulders  to  the  upper  part  of  the  sacrum,  covering  the  nates  to  a  breadth  of  sixty- 
nine  centimetres.  In  length  it  measured  one  metre  fifteen  centimetres,  and  its 
greatest  breadth  reached  one  metre  thirty  centimetres.  Its  pedicle,  which  for 
the  most  part  sprang  from  the  skin  of  the  left  shoulder  and  nape,  measured  fifty- 
eight  centimetres  in  breadth,  and  at  its  left  edge  a  pulsating  artery  could  be  felt, 
the  calibre  of  which  corresponded  to  that  of  the  brachial  artery.  Near  this  a  vein 
was  seen  of  the  thickness  of  the  vena  cava,  which  towards  the  neck  separated  into 
two  branches,  one  seeming  to  join  the  external  jugular,  and  the  other  pursuing 
its  course  towards  the  subclavian  vein.  The  tumour  itself  consisted  of  two  parts 
— a  middle  portion  which  felt  soft  and  lobulated  like  a  lipoma,  and  was  covered 
by  movable  skin ;  and  of  a  much  more  dense  peripheric  portion,  which  was  inti- 
mately united  with  a  thick,  tumefied  skin,  and  conveyed  the  impression  of  a 
fibroma  molluscum.  The  pedicle  of  the  tumour,  although  so  very  thick,  scarcely 
seemed  able  to  sustain  the  great  weight  of  the  tumour,  so  that  its  left  edge  was 
ruptured  to  the  extent  of  three  centimetres. 

The  operation  was  performed  under  carbolic  acid  spray  on  the  day  after  admis- 
sion.   The  large  quantity  of  blood  which  the  tumour  contained  was  forced  back 


2GG 


Progress  of  the  Medical  Sciences. 


into  the  body  by  four  elastic  bandages,  and  an  elastic  tubing  was  then  applied 
around  the  pedicle,  and  prevented  slipping  away  by  means  of  lorn;-  ping,  which 
were  inserted  into  the  pedicle  in  front  of  the  tube.  The  operation  was  then  exe- 
cuted with  ease,  an  anterior  flap  being  first  formed  from  the  skin  of  the  pedicle, 
and  afterwards,  on  the  tumour  being  raised  by  two  strong  assistants,  a  posterior 
flap.  The  large  vessels  which  coursed  through  the  (Edematous  and  hypertrophied 
subcutaneous  tissue  were  secured  by  double  ligatures,  and  divided  between  these. 
The  fascia?  of  the  tumour  were  next  divided,  and  the  tumour  removed.  On  the 
removal  of  the  tubing,  which  had  done  such  good  service,  there  was  only  a  little 
bleeding  from  the  periphery ;  thirty-five  catgut  ligatures  were  applied.  The  re- 
traction of  the  skin  of  the  neck,  which  had  been  anticipated,  did  not  take  place ; 
and  the  flaps  which  had  been  made,  being  too  large,  had  to  be  much  diminished. 
The  wound  was  united  by  thirty-five  sutures,  drainage-tubes  were  inserted,  and 
an  antiseptic  bandage  applied.    The  operation  occupied  two  hours. 

The  tumour  weighed  twenty-five  kilogrammes  (between  fifty  and  sixty  pounds 
avoirdupois),  and  about  a  third  part  of  it  consisted  of  a  lipoma,  which  was  easily 
separable  from  surrounding  parts.  The  remainder  of  the  tumour  was  composed 
of  an  extraordinary  hypertrophy  of  the  connective  tissue,  very  cedematous,  and 
containing  a  gelatinous  infiltration,  covered  by  a  cutis,  which  was  thickened  as  in 
elephantiasis.  The  wound  healed  so  promptly  that  the  man  was  dismissed  on  the 
eighteenth  day  after  the  operation  ;  and  when  he  was  last  heard  of,  in  November, 
the  cure  continued  complete. — Med.  Times  and  Gaz.,  May  18,  1878. 

Narrowing  of  the  Larynx  by  Membranous  Cicatrices  following  Syphilis. 

In  a  paper  in  the  Berliner  Klinische  Wochenschrift  for  April  1st,  Dr.  Som- 
merbuodt,  of  Breslau,  strongly  opposes  the  statements  of  Kaposi  regarding  the 
extreme  painfullness  of  syphilitic  ulceration  of  the  larynx.  He  rather  regards  the 
almost  entire  absence  of  pain  in  laryngeal  ulcers  as  diagnostic  of  syphilis,  seeing 
that  cases  have  often  occurred  where  the  entire  epiglottis  was  destroyed  by 
ulceration,  while  the  patients  complained  of  little  more  than  discomfort  in  the 
throat;  or  that,  in  cases  of  cough  and  supposed  lung-disease,  the  only  discovera- 
ble disease  consisted  of  a  deep  ulcer  and  defect  of  the  epiglottis;  or  lastly,  that, 
with  extensive  ulcerations  of  the  vocal  cords,  the  only  symptom  was  a  certain 
rough  hoarseness  of  the  voice.  On  the  other  hand,  he  regards  exquisitely  painful 
ulceration  of  the  larynx  and  epiglottis  as  pointing  rather  to  phthisical  affections. 
The  absence  of  pain  in  syphilitic  ulcerations  of  the  larynx  may  indeed  lead  to  the 
danger  of  their  being  overlooked  or  neglected,  though  this  risk  is  somewhat  com- 
pensated by  the  tendency  of  these  ulcers  to  heal  spontaneously,  without  any  per- 
manent bad  results,  excepting  a  certain  functional  derangement  of  the  voice. 
The  number  of  cases  is,  nevertheless,  considerable,  in  which  serious  injury  to  the 
larynx  remained  even  after  a  radical  cure  of  the  original  disease.  Of  these,  the 
most  interesting  and  important  are  those  instances  of  membranous  cicatrices 
stretched  across  the  laryngeal  tube;  since,  on  the  one  hand,  they  involve  the 
gravest  disturbance  of  the  laryngeal  function,  and  also,  on  the  other  hand,  admit 
of  operative  interference.  The  entire  number  of  cases  of  this  kind  on  record 
amount  to  22 — of  these,  6  are  described  by  Elsberg  of  jSTew  York,  while  11  are 
reported  from  the  southeast  of  Europe,  and  the  remainder  by  various  writers 
It  is  somewhat  remarkable  that  three-fourths  of  the  European  cases  occurred  in 
the  extreme  east,  showing  the  natural  indolence  and  apathy  of  the  inhabitants  of 
those  regions,  who  only  seek  aid  when  affected  with  grave  disorder,  especially  if 
the  attendant  pain  be  inconsiderable.  Thus,  the  first  case  observed  by  Tiirck 
(Krankheiten  des  Kehlkopfes,  1866,  pp.  408,  409)  was  that  of  a  man  who,  for 


1878.] 


Surgery. 


267 


three  years  previously,  had  been  the  subject  of  syphilis,  and  in  whom  the  nasal 
bones  had  fallen  in,  and  the  uvula  and  a  large  portion  of  the  soft  palate  had  been 
destroyed,  while  the  vocal  cords  had  become  connected  by  a  membranous  cicatrix 
to  such  an  extent  that  there  remained  in  the  posterior  portion  of  the  rima  glotticlis 
only  a  small  round  opening,  not  much  more  than  one-tenth  of  an  inch  in  diame- 
ter, for  the  admission  of  air. 

In  the  case  described  by  Dr.  Sommerbrodt  himself,  the  patient,  a  woman, 
aged  36  years,  came  under  treatment  on  January  16,  1877.  She  began  to  suffer 
eighteen  months  before  this  from  a  painful  affection  of  the  throat,  with  great  dys- 
phagia ;  then  hoarseness  supervened,  and  latterly,  increasing  dyspnoea,  which 
interfered  with  her  occupations.  The  cervical  glands  on  the  left  side  were  indu- 
rated, the  pharynx  was  normal,  and  her  general  health  fair.  The  epiglottis  was 
strongly  reddened,  the  false  cords  were  injected  and  ulcerated  near  the  anterior 
commissure,  while  their  jagged  edges,  to  the  extent  of  about  one-eighth  of  an 
inch,  were  in  close  contact;  from  below,  the  cedematous  mucous  membrane  pro- 
jected over  the  remaining  portion  of  their  free  border.  The  voice  was  very 
husky,  and  there  was  considerable  dyspnoea  on  walking,  etc.,  while  the  arytenoid 
cartilages  on  both  sides  were  movable.  The  case  was  evidently  syphilitic  in  its 
nature  ;  a  view  confirmed  by  the  results  of  treatment.  The  patient  was  put  upon 
potassium  iodide,  and  after  eight  days  the  mucous  oedema  and  injection  had 
greatly  diminished.  In  fourteen  days  the  commencing  union  of  the  true  cords  at 
their  anterior  third  became  perceptible.  After  six  weeks  it  was  seen  that  the 
true  vocal  cords  were  united  by  means  of  a  uniform  white  and  tense  membranous 
cicatrix,  with  a  free  and  very  thin  posterior  margin,  and  on  its  upper  surface  two 
minute  bloodvessels  ramified,  emerging  from  the  commissure.  When  phonation 
was  attempted,  this  membrane  was  folded  downwards,  so  that  the  arytenoid  car- 
tilages became  closely  approximated.  The  dyspnoea  now  became  much  less, 
though  the  free  space  between  the  laryngeal  wall  and  the  free  margin  of  the 
membrane  continued  extremely  small — about  the  tenth  of  an  inch — and  the  pa- 
tient could  resume  her  occupations  ;  there  remained,  however,  complete  aphonia 
The  patient  took  616  grains  of  potassium  iodide  (40  grammes)  during  the  first 
six  weeks ;  it  was  then  discontinued,  and  during  the  last  five  months  her  condi- 
tion has  remained  stationary. 

In  narrowing  of  the  larynx  by  membranous  cicatrices,  the  voice  is  always  im- 
paired, and  there  also  always  exists  dyspnoea ;  but  the  latter  is  not  always  in 
direct  proportion  to  the  extent  of  the  membrane  and  the  consequent  contraction ; 
for  we  have  in  some  cases  excessive  occlusion  (stenosis),  with  but  slight  dyspnoea, 
owing  to  the  influence  of  habit  and  the  slowness  of  the  process ;  while  in  others 
dyspnoea  may  be  intense,  with  only  slight  narrowing,  but  supervening  rapidly. 
In  the  present  case  the  considerable  concentric  swelling  of  the  laryngeal  mucous 
membrane  was  a  fertile  source  of  dyspnoea,  which  diminished  as  the  swelling 
subsided.  The  true  cords  are,  in  most  cases,  the  seat  of  these  membranous  cica- 
trices, by  which  they  are  either  partially  approximated  or  wholly  united,  so  that 
they  become  nearly  obliterated.  The  opening  left  by  the  membrane  is  mostly 
situated  in  the  posterior  portion  of  the  glottis,  and  is  rounded  or  semilunar.  In 
one  case  (Navratil)  the  opening  was  situated  in  the  middle  of  the  membrane. 
As  to  the  origin  of  the  membrane,  it  is  always  the  result  of  the  healing  of  ulcerated 
and  opposed  surfaces  coming  intojmore  or  less  continuous  contact,  be  the  healing 
spontaneous,  or  the  result  of  appropriate  treatment.  The  actual  process  of  the 
formation,  and  the  time  occupied  thereby,  have  only  been  observed  once  before, 
and  in  the  present  case.  In  the  former  case,  described  by  Rossbach  (Langen- 
beck's  Archiv,  vol.  ix.),  there  was  syphilitic  ulceration  of  the  cords  near  the 
commissure,  and  about  the  right  arytenoid  cartilage.    Under  treatment,  the 


2G8 


Progress  of  the  Medical  Sciences. 


[July 


ulcers  healed ;  but  within  eight  days  the  cords  became  united  by  a  membrane  in 
their  anterior  two- thirds.  In  the  present  case  the  anterior  third  of  the  cords  was 
united  after  fourteen  days'  treatment,  and  the  union  became  complete  after  five 
or  six  weeks.  It  will,  therefore,  always  be  a  matter  of  practical  importance  in 
the  treatment  of  syphilitic  cases  to  institute  an  energetic  and  rapid  anti-syphilitic 
treatment  on  the  first  appearance  of  redness  and  swelling  about  the  anterior  com- 
missure of  the  vocal  cords ;  for  if  ulceration  have  once  commenced,  more  or  less 
extensive  union  is  almost  necessarily  a  consequence  of  cure.  If  cicatrization  and 
union  have  actually  taken  place,  the  only  alternative  of  operative  treatment 
remains.  The  division  of  the  membrane  may  be  effected  by  means  of  a  fine 
probe-pointed  bistoury.  But  a  simple  incision  is  followed  in  many  cases  by  only 
temporary  results.  The  galvanic  cautery,  or  caustic  potash,  will  probably  be 
found  more  effectual  in  procuring  a  permanent  destruction  of  the  membrane,  but 
even  the  most  favourable  result  will  scarcely  obtain  a  restoration  of  the  voice ; 
dyspnoea  will,  on  the  other  hand,  always  be  removed.  The  patient  in  the  pres- 
ent case  has  not  consented  to  an  operative  treatment :  want  of  voice  being  her 
only  affection,  and  to  this  she  attaches  no  particular  value. — London  Med.  Record, 
May  15,  1878. 

Enter  otomy. 

Dr.  von  Langenbeck,  at  the  late  congress  of  the  Society  of  German  Surgeons, 
showed  a  patient  on  whom  he  had  performed  enterotomy  last  May,  and  who  wore 
an  India-rubber  bladder  as  an  obturator  to  the  artificial  anus.  He  called  atten- 
tion to  the  importance  of  providing  a  sufficient  closure  for  the  new  opening.  In  a 
case  of  colotomy,  performed  on  a  child  for  absence  of  the  rectum,  and  which 
was  in  other  respects  successful,  death  had  occurred  from  prolapse  of  the  intes- 
tine, in  consequence  of  the  want  of  a  proper  obturator. 

Dr.  Trendelenburg  (Rostock)  had  performed  enterotomy  three  times,  and 
considered  it  much  less  dangerous  than  colotomy,  in  consequence  of  the  injury  to  the 
soft  parts  being  less.  F or  the  closure  of  the  fistula,  remaining  after  gastrotomy, 
he  recommended  a  drainage-tube  provided  with  a  stopcock,  which  could  be  fixed 
securely  in  a  perpendicular  direction  by  means  of  a  ring  of  cork. 

Dr.  Czerny  (Heidelberg)  thought  that,  independently  of  the  connection  in  size 
between  the  prolapsed  portion  of  bowel  and  the  opening,  the  prolapse  was  always 
absent,  or  very  small,  when  there  was  adhesion  of  the  serous  membrane  above  the 
opening. 

Dr.  von  Langenbeck  said,  in  order  to  prevent  misunderstanding,  that  in  the 
case  of  the  child  to  which  he  had  referred  he  had  not  performed  Amussat's  opera- 
tion, but  had  opened  the  flexure  of  the  colon.  He  had  made  the  opening  very 
small,  and  he  believed  that  the  prolapse  was  the  result  of  invagination.  A  means 
of  preventing  prolapse,  not  unattended  with  danger,  but  certain  in  action,  was  the 
use  of  a  plug  to  be  inserted  into  the  intestine.  One  of  his  patients  had  for  some 
years  used  this  plan  with  success. — Lond.  Med.  Record,  May  15,  1878. 

Laparotomy  under  Lister's  Antiseptic  Method. 
Dr.  Czerny  (Heidelberg)  related,  at  the  late  congress  of  the  Society  of  German 
Surgeons,  ten  cases  of  laparotomy  which  he  had  performed,  in  which,  in  spite  of 
the  use  of  antiseptic  dressings,  he  had  not  in  all  cases  been  able  to  insure  an  aseptic 
course.  Of  six  cases  of  ovariotomy,  one  patient  died  of  septic  peritonitis,  follow- 
ing sloughing  of  the  pedicle,  which  was  ligatured  and  returned  into  the  abdomen. 
For  ligature  he  used  silk  treated  with  carbolic  acid;  in  the  remaining  five  cases, 
in  all  of  which  the  pedicle  was  returned  and  drainage  was  not  applied,  this  ligature 


1878.] 


Surgery. 


269 


answered  well,  and  was  absorbed.  Removal  of  the  peritoneal  exudation  and 
washing  out  the  abdomen  with  disinfectants  produced  some  improvement,  but 
failed  to  ward  off  death.  In  two  cases  of  supravaginal  hysterotomy  for  uterine 
myomata.  in  which  the  pedicle  was  fixed  in  the  abdominal  wound,  in  a  case  of 
slow  peritonitis  following  an  operation  done  in  consequence  of  a  wrong  diagnosis, 
and  in  a  case  .of  unsuccessful  attempt  to  remove  a  tumour  lying  in  the  neighbour- 
hood of  the  bifurcation  of  the  aorta,  an  aseptic  course  could  not  be  obtained, 
although  none  of  the  four  cases  ended  fatally. — Loud.  Med.  Record,  May  15,  1878. 

Operation  for  Strangulated  Femoral  Hernia,  in  ivhich  an  Anomalous  Obturator 
Artery  was  Divided. 

At  a  recent  meeting  of  the  Clinical  Society  of  London  QMed.  Times  and 
Gaz.,  May  25,  1878),  Mr.  Barker  read  notes  of  this  case.  The  patient,  a 
woman  of  fifty-six,  was  operated  on  in  the  usual  way  on  February  7.  Most  of 
the  constricting  fibres  were  easily  divided  ;  but,  on  severing  some  which  remained, 
embracing  the  neck  closely,  blood  welled  out  of  the  wound.  The  latter  was  en- 
larged and  the  vessel  sought.  As  it  could  not  be  found  and  the  bleeding  soon 
ceased  to  be  severe,  it  was  deemed  advisable  to  apply  pads  over  the  wound  and 
compress  with  bandages.  On  the  8th  the  patient  was  better,  and  on  the  9th 
better  still.  Early  on  the  morning  of  the  10th,  however,  she  took  a  turn  for  the 
worse  (indicating  peritonitis),  and  died  at  5  P.  M.  on  the  same  day.  A  post- 
mortem examination  revealed  acute  peritonitis  with  serous  effusion.  Near  the 
wound,  about  three  or  four  ounces  of  blood  were  found  effused  underneath  the 
peritoneum  in  the  pelvis,  above  and  to  the  right  side  of  the  bladder.  This  blood 
came  from  an  anomalous  obturator  artery  passing  down  on  the  inside  of  the  neck 
of  the  sac.  It  sprang  from  the  epigastric  about  half  an  inch  from  its  origin,  and 
was  completely  severed  at  about  three-fifths  of  an  inch  from  its  commencement. 
Its  vein  lay  to  the  outside  of  the  sac.  The  proximal  end  was  plugged  ;  the  distal 
had  furnished  the  bleeding.  Mr.  Barker  had  remarked  that  his  object  in  bring- 
ing the  case  before  the  Society  was  not  only  that  it  was  a  rare  one,  but  that  he 
hoped  to  elicit  an  expression  of  opinion  from  the  members  as  to  the  best  mode  of 
dealing  with  cases  where  this  rare  accident  had  occurred.  Was  the  artery  to  be 
sought  at  all  costs,  and  ligatured ;  or  was  it,  in  certain  cases,  as  in  this,  to  be  left 
to  itself  controlled  by  pads  ?  He  had,  with  a  good  deal  of  trouble  and  search 
through  English  and  foreign  literature,  succeeded  in  collecting  only  twelve  cases 
where  this  accident  had  occurred  ;  excluding  doubtful  cases  where  no  correct 
record  had  been  given.  Out  of  these,  he  said,  it  was  remarkable  that  in  six  the 
vessel  was  secured  with  ligature  or  hook,  and  in  six  it  was  left  to  itself.  Of  the 
first  six,  two  died ;  and  of  the  second  six,  one  (the  present  case)  died  of  peri- 
tonitis. Without  desiring  to  make  too  much  of  these  facts,  he  thought  that  the 
one  line  of  practice  was  at  all  events  justified  as  well  as  the  other,  although  in 
some  books  very  positive  statements  were  made  as  to  the  urgent  necessity  of 
seeking  the  artery  and  placing  a  ligature  upon  it. 

Mr.  Callender  said  that  he  personally  had  only  once  seen  such  a  case,  and 
that  was  one  of  those  mentioned  by  Mr.  Barker,  which  had  been  under  the  care 
of  Mr.  Stanley.  The  artery  in  that  instance  was  tied,  and  the  patient  did  well.  He 
had  encountered  hemorrhage  in  some  of  his  operations  for  femoral  hernia,  but 
had  always  stopped  it  by  local  pressure.-  When  the  cases  recovered,  it  was  diffi- 
cult to  say  whether  the  blood  came  from  a  wounded  obturator  artery  or  from  a 
vein.  In  the  six  cases  of  wounded  obturator  artery  which  were,  ligatured,  Mr. 
Barker,  who  had  collected  them,  had  said  there  were  two  deaths  ;  that  propor- 
tion of  fatal  cases  was  not  much  greater  than  the  deaths  after  ordinary  operations 


270 


Progress  of  the  Medical  Sciences. 


[July 


for  strangulated  hernia.  He  thought  each  case  should  stand  on  its  own  merits. 
In  some,  pressure  would  suffice ;  in  others,  the  subcutaneous  fat,  etc.,  being 
pushed  aside,  the  artery  might  be  tied.  In  some  cases,  however,  it  would  be 
very  difficult  to  find  it. 

Mr.  Hutchinson  thought  also  that  each  case  should  stand  on  its  own  merits. 
In  the  present  case,  did  Mr.  Barker  think  there  was  any  secondary  hemorrhage  ? 
If  not,  the  cause  of  death  was  evidently  peritonitis.  What  was  the  method 
adopted  for  applying  pressure  ?  He  advocated  the  plugging  of  the  wound  by  a 
sponge  with  a  silk  thread  tied  around  it,  dipped  in  alcohol,  and  then  thrust  deeply 
into  the  wound,  as  generally  the  best  method  of  arresting  the  hemorrhage.  He 
had  had  nO  case  of  wound  of  the  obturator  artery.  Possibly,  if  the  patient  were 
thin,  the  artery  might  be  tied  ;  in  other  cases,  pressure  should  be  applied. 

Mr.  Maunder  said  he  was  personally  grateful  to  the  author  for  the  valuable 
information  conveyed  in  his  paper.  Hunting  up  statistics  was  always  more  or 
less  irksome  and  distasteful,  but  Mr.  Barker  had  done  this  very  efficiently,  and 
had  clearly  indicated  the  line  of  treatment  to  be  adopted.  Doubtless  an  indi- 
vidual case  must  be  treated  on  its  own  merits,  and  in  an  instance  of  severe  hem- 
orrhage the  bleeding  vessel  might  be  Bought  for.  Failing  to  find  this,  compression 
must  be  resorted  to,  and  in  order  that  it  may  be  effectual  the  compressing  body 
should  be  applied  through  the  wound  and  upon  the  actual  source  of  the  bleeding. 
In  the  author's  case,  the  patient  being  stout,  and  the  mode  of  compression  being 
indirect,  all  the  soft  parts  of  the  region  intervening,  pressure  had  probably  very 
little  to  do  with  the  arrest  of  bleeding;  nature  proved  equal  to  the  emergency. 

Mr.  Barker,  in  reply,  said  that  he  had  purposely  excluded  in  his  statistics  all 
cases  in  which  there  was  any  doubt  as  to  the  source  of  the  hemorrhage.  In  some 
books  it  was  emphatically  stated  that  the  artery  should  be  ligatured  ;  so  said  Mr. 
Hey,  Mr.  Lawrence,  etc.  In  his  own  case,  at  the  necropsy  there  appeared  to 
have  been  only  a  small  amount  of  secondary  hemorrhage.  The  pressure  was  ap- 
plied externally,  and  the  wound  was  not  plugged,  as  the  external  pressure  seemed 
to  be  enough. 

Urethritis  following  the  Use  of  Arsenic. 
M.  Saint-Philippe  publishes  in  the  Gazette  M4dicale  de  Bordeaux  two  cases 
in  which  the  internal  administration  of  arsenic  was  followed  by  urethritis.  The 
first  was  a  man  aged  40,  suffering  from  malarial  fever,  for  which  arsenic  was  pre- 
scribed. He  had,  however,  taken  but  a  small  dose  (.1G  grain)  of  the  remedy 
when  he  exhibited  all  the  signs  of  poisoning.  The  following  day  he  was  attacked 
by  urethritis.  He  positively  affirmed  that  he  had  not  been  exposed  for  more 
than  two  months  previously.  The  other  patient  was  put  upon  arsenic  for  some 
skin-trouble,  but  owing  to  a  mistake  he  took  double  the  dose  ordered,  so  that  at  the 
end  of  eight  days  he  had  taken  sixteen  milligrammes  (.64  grain).  Symptoms  of 
poisoning  now  showed  themselves,  and  at  the  same  time  the  commencement  of  a 
well-marked  urethritis,  which  yielded  to  the  usual  treatment  in  fifteen  days.  Here, 
again,  exposure  was  denied  for  a  long  time  previously,  and,  taking  this  case  in 
conjunction  with  the  foregoing,  M.  Saint-Philippe  was  forced  to  admit  an  arseni- 
cal urethritis  ;  nor  does  he  deem  it  illogical  to  suppose  that  arsenic,  while  being 
eliminated  with  the  urine,  may  produce  effects  similar  to  those  produced  in  the 
digestive  tract  and  on  the  skin,  where  it  is  also  eliminated.  As,  however,  this  is 
a  toxic  rather  than  a  physiological  irritation,  the  poisonous,  instead  of  the  simple 
therapeutic  action  of  the  drug,  is  necessary  for  its  production.  Hence  it  is  rarely 
met  with  in  practice.  This  form  of  urethritis  resembles  that  caused  by  certain 
substances  known  to  have  a  very  marked  irritant  action  on  the  genito-urinary 
mucous  membrane,  such  as  cantharides,  certain  balsams,  and  even  beer  and  alco- 
hol in  excess. — Lond.  Med.  Record,  May  15,  1878. 


3  878.] 


Surgery. 


271 


Five  Hundred  Cases  of  Operation  for  Stone  in  the  Bladder  of  the  Male. 

At  a  recent  meeting  of  the  Royal  Medical  and  Chirurgical  Society  Sir  Henry 
Thompson  read  {Med.  Times  and  Gaz.,  March  23,  1878)  an  account  of  500 
cases  of  operation  for  stone  in  the  bladder  of  the  male  adult,  with  remarks  on 
the  most  important  incidents  which  occurred  in  connection  with  them.  The  500 
cases  were  in  adult  males — that  is,  of  twenty  years  old  and  upwards — the  great 
majority  being  from  fifty  to  seventy  years;  the  mean  age  sixty-one  and  a  half. 
They  comprised  the  author's  entire  and  unseleeted  work,  from  the  first  case  up 
to  January,  1877.  The  published  experience  of  Cheselden,  Martineau,  Brodie, 
and  Fero-usson  is  recorded :  the  sum  of  similar  cases  treated,  by  number  422. 
Of  these  422.  69  were  fatal,  or  16^-  per  cent.  (i.  <?.,  one  in  rather  more  than  6 
cases).  Of  the  500  cases  in  question,  422  were  by  lithotrity,  and  78  by  lithot- 
omy. The  number  of  individuals  operated  upon  was  420  ;  several  of  the  lith- 
otrity patients  being  operated  upon  twice,  a  few  three  times.  In  all  cases  a  con- 
siderable interval  and  evidence  of  fresh  formation,  mostly  a  newly  descended 
uric  acid  calculus,  had  existed.  Small  phosphatic  concretions,  although  removed 
by  lithotrity,  had  not  been  reckoned  as  stone  in  the  bladder.  The  chemical 
constitution  of  the  calculi  was  given  as  follows  :  Uric  acid,  313  ;  phosphatic,  99  ; 
mixed,  81  ;  cystic  oxide,  1  ;  pure  phosphate  and  carbonate  of  lime,  2  ;  phos- 
phatic calculi  formed  on  foreign  bodies,  4.  The  mortality,  accepting  almost  any 
death  occurring  within  six  weeks  of  the  operation,  was — in  the  422  cases  of  lith- 
otrity 32  deaths,  or  one  in  13,  and  in  the  78  cases  of  lithotomy  29  deaths,  or  1  in 
2f,  giving  a  total  of  500  cases  with  61  deaths,  or  1  death  in  8-k  cases.  The 
causes  of  death  given  in  each  case  were  tabulated,  compared,  and  contrasted  in 
the  two  operations,  with  inferences  thereupon.  The  accidents  met  with  in  oper- 
ating by  each  mode  were  also  detailed,  and  the  manner  in  which  they  were  dealt 
with.  The  general  inference  arrived  at  was,  that  it  is  unwise  to  apply,  as  a  rule, 
lithotrity  to  any  stones  above  moderate  size ;  and  if  any  calculus  is  sufficiently 
large  to  require  what  is  known  as  the  fenestrated  instrument,  it  is  better  to  em- 
ploy lithotomy.  The  author  had  not  employed  such  an  instrument  during  the 
last  ten  years.  Finally,  the  after-history  of  patients  who  had  been  operated  on 
by  lithotrity  was  remarked  upon. 

Mr.  Cadge,  of  Norwich,  said  that  the  paper  prompted  the  question,  What  are 
the  relative  values  of  lithotomy  and  lithotrity  in  operative  proceeding  ?  The  time 
had  finally  come  when  the  mortality  of  lithotrity  might  be  estimated.  Sir  Henry 
Thompson's  experience  gave  a  mortality  of  32  out  of  422  cases,  or  in  all  8  per 
cent.  Taking  the  experience  of  Brodie,  Fergusson,  Liston,  Keith,  his  own,  and 
the  author's,  there  were  892  cases  with  74  deaths,  giving  a  total  mortality  of  8  per 
cent.  ;  and  this  might  be  taken  as  the  average  mortality  after  lithotrity.  In  lith- 
otomy the  author  admitted  a  mortality  of  20  per  cent.,  but  this  was  hardly  a  fair 
comparison,  for  if  Mr.  Crosse's  Norwich  tables  were  taken,  the  average  age  was 
higher  than  in  Sir  H.  Thompson's  cases,  and  the  death-rate  as  much  as  31  per 
cent.  This  certainly  showed  that  in  all  patients  above  fifty  the  immediate  dan- 
ger from  lithotomy  was  very  much  greater  than  from  lithotrity.  But  in  cases 
of  lithotomy  the  stone  was  usually  larger  and  heavier,  and  this  was  an  important 
factor  in  the  case.  The  result  was  that  the  total  mortality  had  been  reduced  in 
all  cases  from  31  to  12  per  cent.  His  own  experience  tallied  closely  with  this. 
He  had  operated  in  all  on  220  patients— on  134  by  lithotomy,  on  86  by  lithotrity. 
[n  lithotomy  104  were  adults  and  30  below  twenty  years  of  age ;  of  the  former 
20  per  cent,  died ;  of  the  lithotrity  cases  8  died.  Recurrence  of  the  stone  was, 
however,  rare  in  lithotomy  ;  in  700  operations  Crosse  found  only  12,  and  this  ap- 
peared to  be  due  to  leaving  fragments  behind ;  but  this  recurrence  was  compara- 


272 


Progress  of  the  Medical  Sciences. 


[July 


tively  common  in  lithotrity,  and  was  one  of  its  chief  defects.  Another  was  the 
cystitis  which  was  often  left  after  lithotrity,  and  which  Sir  H.  Thompson  con- 
sidered unavoidable,  and  due  to  fragments  or  the  repeated  use  of  instruments.  A 
more  frequent  cause  was,  however,  sacculated  bladder  from  enlarged  prostate 
and  accumulation  of  matters  in  the  bladder.  The  formation  of  stone  in  the  blad- 
der was  exceedingly  rare  ;  when  such  did  form  it  was  usually  from  the  remains 
of  a  former  calculus.  Then,  after  operation,  there  were  not  only  those  who  died 
or  recovered,  but  those  also  in  whom  the  stone  remained,  and  he  thought  this  list 
much  longer  in  lithotrity  than  lithotomy.  And  notwithstanding  the  fact  that 
such  was  the  case,  he  thought  lithotrity  an  enormous  boon. 

Sir  James  Paget  thought  it  was  now  fair  to  compare  the  results  of  lithotomy 
and  lithotrity,  but  he  confessed  to  a  general  feeling  in  favour  of  lithotomy.  The 
main  ground  of  his  preference  was  expressed  by  the  list  of  those  who  neither  died 
nor  recovered  after  lithotrity.  He  thought  that  those  cases  of  cystitis  where 
death  ensued  within  twelve  months  should  be  included  in  the  mortality  it'  the 
cystitis  could  be  clearly  traced  to  the  operation.  The  two  operations  ought  to  be 
fully  compared  in  every  possible  way,  including  the  pain  and  suffering  after  lith- 
otrity and  the  not  unfrequent  recurrence  of  stone.  Moreover,  it  was  doubtful, 
after  all  the  improvements  made  by  Sir  H.  Thompson,  if  any  further  were  to  be 
looked  for  in  this  direction  for  some  time  to  come.  There  was  much  scope,  how- 
ever, in  the  after-treatment  of  lithotomy  and  in  carefully  selecting  patients. 
Were  he  to  begin  surgical  work  again,  he  would  adhere  to  lithotomy,  using  lith- 
otrity for  cases  where  the  stone  could  be  got  rid  of  in  a  few  sittings.  He  was 
sure  the  mortality  after  lithotrity  could  be  reduced  one-half. 

Treatment  of  Hydrocele  by  Electricity. 

Signer  Macario  reports  (Gaz.  Med.  Ital.,  Lombard^  Xo.  30.  1877)  two 
cases  of  hydrocele  treated  by  a  single  application  of  an  electrie  needle  for  the 
space  of  one  minute.  One  of  these  cases  was  permanently  cured;  the  other  was 
only  temporarily  cured,  the  disease  returning  after  ten  months.  In  both  in- 
stances the  fluid  entirely  disappeared  in  the  course  of  twenty-four  hours,  though 
no  fluid  escaped  through  the  wound  made  by  the  introduction  of  the  needle. 
Macario  recommends  the  employment  of  this  method  in  other  kinds  of  cysts, 
especially  for  ovarian  cysts,  and  cites  three  cases  that  have  been  published  as 
cured  by  this  means. — Practitioner,  May,  1878. 

Disarticulation  of  Hip. 
Towards  the  end  of  1877,  M.  Verneuil  communicated  to  the  Academy  of 
Medicine  in  Paris  a  paper  on  this  subject,  with  remarks  on  the  operative  proceed- 
ing and  mode  of  dressing.  This  paper  became  the  starting-point  of  a  long  dis- 
cussion, in  which  all  the  surgical  celebrities  of  Paris  have  in  succession  taken 
part.  Disarticulation  of  the  hip,  says  M,  Verneuil  in  his  memoir,  will  always 
involve  a  grave  prognosis,  on  the  one  hand  by  reason  of  the  dangers  inherent  to 
the  conditions  which  necessitate  it,  on  the  other  by  reason  of  the  traumatic  acci- 
dents to  which  it  is  exposed  by  reason  of  the  extent  of  the  wound.  "  Death," 
he  adds,  "  is  sometimes  immediate,  on  the  operating-table  itself;  sometimes 
rapid  in  the  first  five  hours  ;  sometimes  approximate  within  two  hours.  At  other 
times,  it  occurs  after  the  fi'st  seven  days,  or  later.  Early  deaths  are  by  much  the 
most  frequent,  ordinarily  caused  by  the  hemorrhage  which  precedes,  accompanies, 
or  follows  the  operation,  and  which  proceeds  not  only  from  the  femoral  artery, 
but  also  from  the  branches  of  the  gluteal  and  the  sciatic  arteries.  Later  deaths 
are  most  frequently  the  result  of  blood-poisoning."    M.  Verneuil  then  attempts 


1878.] 


Surgery. 


273 


to  discover,  first,  what  is  the  mode  of  operation  most  calculated  to  realize  economy 
of  blood ;  and,  second,  what  is  the  mode  of  dressing  which  affords  the  best  pre- 
caution against  the  accidents  of  infection.  To  reduce  the  loss  of  blood  to  its 
minimum,  the  best  method,  according  to  M.  Verneuil,  consists  first  in  pushing 
back  into  the  system  the  blood  contained  in  the  limbs  by  means  of  the  elastic 
bandage ;  then  removing  the  thigh  as  if  one  were  proceeding  to  remove  a 
voluminous  tumour,  by  exposing  and  tying  the  principal  vessels  before  dividing 
them.  This  method  of  proceeding  was  followed  for  the  first  time  by  M.  Ver- 
neuil in  1864.  To  prevent  septicemia  in  its  diverse  forms,  acute,  chronic,  or 
pyemic,  M.  Verneuil  considers  it  essential  to  prevent  the  discharges  from  stag- 
nating in  the  wound,  too  favourably  disposed  to  retain  them ;  and  useful,  if  it  be 
possible,  to  prevent  changes  in  those  fluids.  Primary  union,  adopted  by  all  sur- 
geons and  held  in  view  by  all  the  inventors  of  operative  methods,  is,  he  con- 
siders, unfit  to  fulfil  the  two  former  conditions ;  it  favours  rather  the  alteration 
and  retention  of  the  fluids,  even  if  only  in  the  cotyloid  cavity.  It  ought,  he  ad- 
vises, to  be  abandoned.  For  the  same  reason,  M.  Verneuil  abandons  the  lateral 
oval  proceeding,  and  the  operation  by  the  anterior  flap,  which  favours  retention 
of  the  fluids,  and  prefers  an  open  wound  largely  exposed,  such  as  he  obtains  by 
the  "racquet"  method.  The  following  are  the  different  stages  of  this  proce- 
dure. In  the  first  stage,  an  incision  is  made  in  the  skin — a  vertical  incision  from 
2  to  2.4  inches,  starting  from  a  finger's  breadth  below  the  crural  arch  ;  and 
from  the  inferior  extremity  of  this  is  made  an  incision  which  crosses  obliquely 
the  external  surface  of  the  great  trochanter,  and  is  continued  along  the  gluteal 
fold.  The  second  stage  consists  of  opening  the  sheath  of  the  vessels  ;  preventive 
ligature  of  the  femoral  artery  above  its  bifurcation,  and  ligature  of  its  two 
branches  en  masse  to  avoid  the  reflex  hemorrhage  by  anastomosis ;  and  section 
of  the  veins  between  the  ligatures.  The  third  stage  consists  of  section  with  the 
bistoury  of  the  muscles  of  the  anterior  region.  The  vessels  compressed  in  the 
muscular  interstices  are  only  divided  after  previous  ligature.  In  the  fourth  stage, 
the  joint  is  laid  open.  The  first  stage  consists  of  division  of  the  posterior  mus- 
cles and  of  the  vessels  with  the  same  precautions.  The  operation  may  be  termi- 
nated in  half  an  hour.  The  wound  is  open,  and  shaped  like  a  hollow  cone.  As 
to  dressing,  M.  Verneuil  employs  small  squares  of  tarlatan  soaked  in  water,  on 
which  are  applied  small  feathery  masses  of  charpie  dipped  in  antiseptic  liquids, 
which  are  covered  with  a  thick  layer  of  cotton- wool.  The  whole  is  kept  in  place 
by  a  piece  of  oiled  silk  as  simply  arranged  as  possible.  The  dressing  (a  la  Lister 
modijii)  is  rearranged  every  morning. 

All  the  surgeons  who  followed  M.  Verneuil  in  the  discussion  admitted  the 
originality  of  his  method.  M.  Roche,  however,  observed  that  Marcellin  Duval 
had  already  previously  substituted  the  bistoury  for  the  knife ;  but  his  proceeding 
differed  essentially  from  that  of  M.  Verneuil,  in  that  the  vessels  were  not  tied 
until  after  the  operation.  M.  Terrillon  preferred  the  external  oval  method  ;  he 
compressed  the  aorta  and  tied  the  vessels  as  he  proceeded  with  the  section.  M. 
Richet  recommended  direct  compression  of  the  open  arteries  by  the  aid  of  large 
sponges,  soaked,  if  desired,  in  haemostatic  fluids.  Two  operations  performed 
with  these  precautions — one  in  1850,  and  the  other  in  1864 — ended  both  success- 
fully ;  whilst  a  first  disarticulation,  performed  in  June,  1848,  resulted  in  consider- 
able hemorrhage  and  the  death  of  the  patient  in  forty-eight  hours.  M.  Trelat 
compressed  the  iliac  and  performed  preliminary  ligature,  or  prompt  ligature  of 
divided  vessels,  whilst  an  assistant  compressed  the  whole  base  of  the  anterior  flap. 
As  for  the  posterior  flap,  "what  prevents  us,"  he  asked,  "from  proceeding 
slowly  and  applying  the  haemostatic  forceps  to  every  branch  which  gives  blood?" 
M.  Legouest  had  three  times  performed  disarticulation  of  the  thigh,  and  had  as- 
No.  CLI — July  1878.  18 


274 


Progress  of  the  Medical  Sciences. 


[July 


sisted  at  an  equal  number  of  operations.  The  first  of  his  patients  died  at  the 
end  of  four  months ;  the  second,  at  the  end  of  forty-eight  hours  ;  and  the  third, 
at  the  end  of  fifteen  days.  In  the  first  and  third  operations,  there  was  abundant 
hemorrhage.  M.  Legouest  advised  the  prevention  of  hemorrhage  from  the 
femoral  and  its  branches  by  employing  the  procedure  by  the  anterior  flap,  and 
tying  immediately  the  vessels  which  it  contains.  Having  uncovered  the  articu- 
lation, he  disengaged  the  head  of  the  femur ;  and,  separating  it  from  the  pelvis, 
he  passed  behind  it  the  flat  of  the  knife,  so  as  to  divide  at  the  same  time  the  pos- 
terior soft  parts  in  front  of  the  hands  of  an  assistant  who  compresses  them,  stop- 
ping to  tie  the  vessels  as  they  are  opened.  Finally,  M.  Lefort  was  of  opinion 
that  the  sometimes  abundant  hemorrhage  which  often  accompanies  this  operation 
is  not  the  principal  cause  of  the  rapidly  fatal  result.  This  frightful  mutilation, 
by  cutting  off"  almost  a  fourth  in  weight  of  the  body,  carries  with  the  limb  a  quan- 
tity of  arterial  and  venous  blood  greater  than  that  of  which  even  abundant  hem- 
orrhage may  cause  the  loss.  This  loss,  added  to  that  which  occurs  by  the  vessels 
which  the  surgeon  opens,  augments  in  a  formidable  proportion  the  gravity  of 
the  operation  ;  and  to  this  must  be  added  the  modification  which  must  occur  in 
the  hydrostatics  of  the  circulation  by  the  removal  of  so  considerable  a  part  of  the 
body.  The  relative  benignity  of  disarticulation  in  patients  whose  thighs  have 
already  been  amputated  at  a  more  or  less  distant  time,  the  successful  employment 
of  Esmarch's  bandage,  and  the  observations  of  Joseph  Bell  at  the  lioyal  Infir- 
mary of  Edinburgh,  have  led  M.  Legouest  to  insist  upon  this  particular  part  of 
the  question.  The  economy  of  blood  deserves,  then,  the  attention  of  all  sur- 
geons in  performing  coxo-femoral  disarticulation  ;  and  it  follows  from  the  commu- 
nications of  all  those  surgeons,  that  it  is  absolutely  indispensable  to  employ  ever} 
means  capable  of  lessening  loss  of  blood  either  as  a  preventive  or  definite  means. 

M.  Gros  of  Nancy,  in  reviewing  this  long  debate  in  the  Revue  M^dicale  de 
V  Est,  which  is  the  organ  of  the  new  University  at  Nancy,  calls  attention  to  the 
very  complete  memoir  recently  published  on  coxo-femoral  disarticulation  by  Dr. 
Luning  of  Zurich  (  Ueber  die  Blutung  hex  der  Exarticulation  des  Oberschenkels  und 
deren  Vermeidung,  Zurich,  1877).  Dr.  Luning,  he  pointed  out,  had  collected 
four  hundred  and  ninety-seven  observations  on  disarticulation  of  the  hip,  in  which 
the  mortality  is  as  high  as  70  per  cent.  ;  but  it  has  been  ameliorated  of  late  years. 
It  is  greatest  in  operations  performed  for  wounds  by  firearms,  and  hardly  better 
in  operations  performed  for  ordinary  injuries  (71  per  cent.)  ;  more  favourable  in 
operations  performed  for  pathological  lesions  (42  per  cent.)  ;  and  most  so  in 
cases  of  reamputation  (40  per  cent.)  In  two  hundred  and  thirty-nine  operations 
having  a  bad  result,  and  in  which  the  date  of  death  is  exactly  known,  Dr.  Lli- 
ning  has  noted  that  in  5  per  cent,  of  the  cases  the  patient  has  succumbed  during 
the  operation;  in  12^  per  100,  within  one  hour;  in  26,  within  five  hours  ;  in  46 
per  100,  or  nearly  one-half  of  the  cases,  within  the  first  day  ;  in  57  per  100  of 
the  cases,  within  forty-eight  hours;  and,  finally,  in  70  per  100  of  the  case-, 
bofore  the  fifth  day, — British  Med.  Journal,  April  27,  1878. 

Treatment  of  Aneurism  of  the  Aorta  by  Electro-Puncture. 
At  the  meeting  of  the  Paris  Societe  de  Therapeutique  on  March  13th,  M. 
Dujakdin-Beatjmetz  stated  that  this  method  of  treatment  was  becoming  gene- 
ral in  France.  Since  last  July,  the  operation  has  been  performed  three  times  ; 
on  two  patients  in  M.  Potain's  wards,  and  on  a  patient  of  M.  Ball's.  A  very 
marked  improvement  was  obtained  by  this  method  in  all  the  cases.  The  aneu- 
risms were  all  of  the  thoracic  aorta — two  were  seated  at  the  origin  of  the  aorta, 
and  formed  sacs  occupying  the  left  side  of  the  thorax  ;  a  third  was  situated  at  the 


1878.] 


Surgery. 


275 


dorsal  region,  and  originated  in  the  descending  portion  of  the  arch  of  the  aorta ; 
in  the  latter  case,  the  tumour  was  the  cause  of  paraplegia.  Five  applications 
were  made  at  intervals  of  three  weeks,  and  produced  a  diminution  in  the  para- 
plegia, and  a  great  lessening  of  the  pulsations.  These  aneurisms  were  not  accom- 
panied by  any  cardiac  change.  The  method  of  operation  was  the  same  in  all  the 
eases  ;  positive  currents  only  were  used  on  the  needles  inserted  in  the  tumour,  the 
negative  pole  being  applied  on  the  thigh.  M.  Dujardin-Beaumetz  is  inclined  to 
believe  that  electricity  acts  here  by  setting  up  inflammation  on  the  sac  rather  than 
by  directly  bringing,  on  coagulation  of  the  albumen  and  fibrin.  He  thus  explains 
the  tardy  setting  in  of  improvement,  which  only  comes  on  from  a  week  to  a  fort- 
night after  the  application  of  electricity.  Summing  up  the  facts  known  up  to  the 
present  time,  M.  Dujardin-Beaumetz  is  of  opinion  that,  taking  the  harmlessness 
of  electro-puncture  into  consideration,  this  plan  should  take  its  place  in  ordinary 
therapeutics,  and  that  it  is  the  best  of  all  treatments  recommended  up  to  the  pre- 
sent time  ;  he,  however,  acknowledges  that  ice  and  iodide  of  potassium  must  first 
be  tried.  lee  applied  externally  also  acts  by  setting  up  inflammation  in  the  sac, 
and  not  by  directly  eoagulating  the  blood  ;  it  has,  in  fact,  been  demonstrated  that 
cold  retards  coagulation  of  the  blood.  Iodide  of  potassium  administered  internally 
is  the  only  remedy  which  has  afforded  certain  cures.  At  the  same  meeting,  M. 
Paid  stated  that  he  had  recently  seen  a  case  of  aneurism  of  the  brachio-cephalic 
artery  in  a  syphilitic  patient,  which  was  cured  by  the  use  of  iodide  of  potassium. 
M.  Edouard  Labbe  also  pointed  out  that  M.  Potain  had  observed  an  analogous 
ease.  M.  Baequoy  also  mentioned  that  he  had  seen  two  cases  of  very  remarkable 
improvement  in  aneurism  of  the  aorta,  by  the  use  of  iodide  of  potassium  and  ice. 
— British  Med.  Journal,  May  4,  1878. 

Ihe  History  of  Complete  Extirpation  of  the  Scapula. 
Dr.  von  Adelmann  (Dorpat),  at  the  late  Congress  of  the  Society  of  German 
Surgeons,  read  a  paper  on  sixty-one  cases  of  total  extirpation  of  the  scapula  which 
he  had  collected,  and  commented  on  the  principal  clinical  facts.  He  remarked 
that  it  was  an  especially  encouraging  fact  that  this  operation,  formerly  feared  as 
very  dangerous,  had  been  performed  with  comparative  frequency  during  the  last 
twenty  years,  with  good  results. — Lond.  Med.  Record,  May  15,  1878. 

Extirpation  of  the  Scapula  and  a  Portion  of  the  Clavicle. 

In  the  Archiv  fur  Klinische  Chirurgie.  Band  xxi.,  Dr.  Nedopil  describes  a 
case  in  which  this  operation  was  performed  by  Dr.  Billroth. 

A  man,  aged  44,  had  a  tumour  on  the  scapula.  It  first  began  to  give  trouble 
three  years  before  the  patient  came  under  treatment,  and  had  extended  into  the 
supraspinous  and  infraspinous  fossa?,  to  the  neighbourhood  of  thecoracoid  process, 
and  into  the  axilla.  An  exploratory  puncture  having  been  made,  and  a  portion 
removed,  the  diagnosis  of  myxochondroma  was  made. 

The  operation  of  removal  was  performed  in  the  following  manner :  The  tumour 
was  first  laid  bare  by  an  incision  nearly  corresponding  to  the  median  border  of 
the  scapula  ;  from  the  upper  end  of  this,  a  semilunar  incision  was  carried  out- 
wards over  the  acromion,  and  then  inwards  and  downwards  over  the  coracoid 
process.  It  was  now  found  that  the  arm  could  be  preserved.  The  shoulder- 
joint  was  laid  open  from  above,  and  the  arm  drawn  out ;  the  tumour  was  then 
separated  from  its  muscular  connections,  proceeding  from  before  backwards.  As 
the  lower  angle  of  the  scapula  was  sound  for  a  length  of  more  than  three  inches, 
it  was  separated  by  means  of  bone-forceps  from  the  diseased  part  and  preserved, 
while  the  greater  part  of  the  scapula,  which  was  involved  in  the  growth,  as  well 


276 


Progress  of  the  Medical  Scien 


[July 


as  the  acromial  end  of  the  clavicle,  around  which  the  tumour  had  grown,  were 
removed.  Drainage-tubes  and  sutures  were  applied,  and  antiseptic  treatment 
was  followed.  At  the  end  of  three  weeks  healing  was  complete,  except  at  a 
small  granulating  surface  at  the  point  of  drainage.  Six  weeks  after  the  opera- 
tion, the  head  of  the  humerus  had  formed  an  articulation  with  the  outer  end  of 
the  clavicle  and  the  remaining  portion  of  the  scapula,  and  could  be  actively  ro- 
tated inwards  and  outwards,  the  teres  major  and  teres  minor  having  been  pre- 
served. The  movements  of  the  forearm  and  hand  were  powerful. — London 
Med.  Record,  March  15,  1858. 

Resection  of  the  Ribs  in  Cases  of  Retrocostal  Abscess. 
Dr.  Lossen,  Professor  of  Surgery  in  Heidelberg,  writes  in  the  Berliner  Klin- 
ische  Wochenschrift  for3Iarch  4  that  resection  of  the  ribs  in  retrocostal  abscesses 
was  first  recommended  by  Roser  in  1859.  His  object  was  the  permanent  dilata- 
tion of  the  empyematous  fistulas,  which  usually  show  a  strong  tendency  to  con- 
tract, principally  through  the  close  approximation  of  the  adjacent  ribs,  whereby 
the  introduction  of  tubes  and  canulas  is  rendered  well  nigh  impossible.  A  case 
of  empyematous  fistula  of  eight  years'  standing  was  thus  treated  by  Roser  in  1865, 
after  which  it  rapidly  healed  in  fourteen  days.  In  1869,  Simon  excised  a  portion 
of  the  sixth  rib  in  a  case  of  empyema  with  fistula  (Berl.  Klin.  Wochenschrift, 
1876,  No.  19),  with  the  object  of  permanently  dilating  the  canal.  After  a  few 
weeks  the  edges  of  the  wound  again  came  so  close  together,  that  only  a  fine  sound 
could  be  introduced.  At  the  same  time,  however,  the  suppurating  cavity  had 
become  much  smaller,  and  ultimately  became  completely  obliterated,  while  there 
remained  a  marked  sinking  in  of  the  sixth  rib.  This  led  Simon  to  the  conclusion 
that  the  sinking  in  of  the  rib  was  the  immediate  cause  of  the  closing  of  the  cavity, 
which  was  before  impossible,  owing  to  the  rigidity  of  the  walls ;  for  the  ribs,  with 
their  cartilages  and  attached  muscles,  form  a  pretty  rigid  external  wall  to  the 
pleural  cavities,  whose  dimensions  can  only  be  altered  by  elevation  or  depression 
of  the  ribs,  but  not  by  any  change  in  the  curvature  of  the  individual  ribs,  which 
is  impossible.  In  long-standing  empyema,  the  affected  side  of  the  thorax  is  in 
the  condition  of  expiration.  The  ribs  are  depressed  and  still  further  approximated 
by  adhesions,  and  even  in  immediate  contact.  The  posterior  wall  of  the  cavity, 
being  formed  by  the  lung,  is,  on  the  contrary,  more  movable  and  less  resistant,  pro- 
vided the  lung  itself  is  not  tied  doAvn  to  the  neighbouring  thoracic  wall  by  adhesive 
bands.  If  we  now  remove  a  portion  of  the  costal  arch,  the  walls  of  the  cavity  can 
approach  and  come  into  contact ;  and  the  abscess  heals.  Three  cases  thus  treated 
within  the  last  few  years  by  Stehberger  and  Peitavy  by  section  of  the  ribs,  bear 
out  this  view,  which  is  also  confirmed  by  the  following  case.  In  October,  1878, 
a  young  lady,  nineteen  years  of  age,  presented  herself  with  a  fistulous  opening  on 
the  right  side  of  the  thorax.  When  she  was  two  years  old.  an  abscess  had  formed 
in  this  situation,  from  which,  when  opened,  a  large  darning  needle  was  removed. 
How  the  needle  had  come  there  could  never  be  made  out.  In  spite  of  all  treat- 
ment a  fistulous  opening  remained,  with  a  constant  discharge  of  pus.  It  was  so 
narrow  that  only  a  fine  probe  could  be  introduced.  Dr.  Lossen,  therefore,  re- 
moved a  piece  about  two-thirds  of  an  inch  in  length,  of  both  the  sixth  and  seventh 
ribs,  whereupon  a  cavity  of  the  size  of  a  fist  was  reached,  containing  a  consider- 
able quantity  of  thick  pus,  and  extending  towards  the  axilla.  Under  a  treatment 
consisting  of  carbolic  injections,  drainage,  etc.,  the  cavity  diminished  considerably, 
and  the  adjacent  ribs  sank  inwards,  while  the  patient,  whose  general  health  had 
latterly  become  much  impaired,  improved  in  every  respect.  In  March,  the  ends 
of  the  ribs  had  approached  so  closely  by  cicatrization  that  it  became  extremcly 
difticult  to  keep  the  sinus  open  for  the  purpose  of  injection,  while,  at  the  same 


1878.] 


Surgery. 


277 


time,  there  clearly  still  existed  behind  it  a  pouch  nearly  two  and  one-half  inches 
(six  centimetres)  in  depth.  Consequently  Dr.  Lossen  further  removed,  on  April 
10th,  a  piece  about  one  and  two-thirds  inch  long  from  the  upper  rib,  and  a  piece 
about  one  and  four-fifths  inch  from  the  lower  one,  whereby  almost  the  entire 
cavity  was  laid  bare.  The  patient  now  did  well ;  the  ribs  were  drawn  still  further 
inwards,  while  a  few  small  pieces  of  bone  came  away  through  the  now  shallow 
opening.  The  case  is  instructive,  as  showing  the  mode  in  which  a  radical  cure 
was  effected ;  and  the  necessity  for  a  second  resection  proves  the  importance  of 
removing  a  fairly  large  portion  of  the  rib. — London  Med.  Record,  May  15,  1878. 

Disarticulation  at  the  Knee-joint. 

Dr.  vox  Langenbeck  showed,  at  the  Congress  of  the  Society  of  German 
Surgeons,  two  patients  on  whom  this  operation  had  been  performed.  Under  the 
present  system  of  dressing  wounds,  it  was  attended  with  much  less  danger  than 
amputation  at  the  lower  part  of  the  thigh,  and  the  result  as  regarded  utility  of 
the  limb  was  very  good.  Disarticulation  at  the  knee  was  indicated  in  cases  of 
entire  or  partial  destruction  of  the  joint,  and  in  cases  of  injury  of  the  leg  not  im- 
plicating the  knee.  In  the  first  case,  the  leg  being  strongly  bent,  the  articular 
surfaces  of  the  femur  were  simply  removed.  He  had  performed  this  operation 
three  times  since  1851,  with  satisfactory  results  in  all  the  cases.  The  operation 
had  been  clone  by  him  in  seven  cases  with  uninjured  joint  since  1871 ;  in  the  case 
now  shown  the  patella  had  been  preserved.  He  submitted  the  question  of  the 
preservation  of  the  patella,  in  cases  where  the  knee-joint  was  uninjured,  to  the 
Society  for  discussion;  as,  even  under  antiseptic  treatment,  the  bursa  of  the 
quadriceps  could  not  remain  unopened,  but  must  be  drained.  He  would  always 
remove  the  patella  along  with  the  bursa  and  the  whole  of  the  capsule,  although 
in  his  seven  operations  he  had  had  two  deaths,  as  well  as  a  case  of  pyaemia. 

Dr.  Uhde  (Brunswick)  who  had  had  twelve  cases  of  amputation  at  the  knee, 
as  well  as  several  of  disarticulation  at  the  elbow,  recommended  the  preservation 
of  the  patella.  He  had  lost  only  one  or  two  patients.;  all  his  cases  of  disarticu- 
lation at  the  elbow  had  recovered. 

Dr.  Lucke  (Strasburg),  who  had  seen  sloughing  at  the  anterior  flap  in  two 
cases  of  amputation  at  the  knee-joint,  asked  whether  this  might  be  obviated  by 
leaving  the  patella,  or  whether  any  other  method  than  that  by  anterior  flap  could 
be  followed. 

Dr.  Schede,  who  remarked  that  amputation  at  the  knee-joint  was  not  suffi- 
ciently practised  in  Germany,  believed  that  in  it  healing  by  the  first  intention  was 
insured  by  antiseptic  treatment,  and  that  it  was  seldom  if  ever  followed  by 
atrophy  of  the  stump,  such  as  occurred  after  amputation  through  the  femur. 
With  regard  to  the  question  of  total  extirpation  of  the  capsule  along  with  the 
patella,  he  was  of  opinion  that  the  retention  of  the  synovial  membrane  was  of 
little  importance,  while  on  the  other  hand  there  was  no  special  indication  for 
removing  the  patella.  The  mortality  after  disarticulation  at  the  knee-joint  less- 
ened yearly  ;  according  to  Andrews,  of  Chicago,  it  was  now  not  greater  than  that 
after  amputation  through  the  condyles. 

Dr.  vox  Laxgexbeck  would  perform  disarticulation  at  the  knee  in  place  of 
amputation  of  the  thigh  high  up,  in  cases  where  an  artificial  foot  would  have  to 
be  used.  Differing  from  Dr.  Uhde,  who  advocated  Velpeau's  modification  of 
the  circular  incision,  he  recommended  an  anterior  flap,  the  only  disadvantage  at- 
tending which  was  that  the  process  of  union  by  the  first  intention  was  liable  to  be 
disturbed  by  muscular  spasm. 

Dr.  Riedingek  (Wiirzburg)  had  seen  sloughing  of  the  flap  in  the  last  two 


278 


Progress  of  the  Medical  Sciences. 


[July 


cases  of  disarticulation  at  the  knee  performed  in  Wiirzburg;  one  patient  was  a 
blooming  girl  ten  years  old. 

Dr.  Thiersch  (Leipsic)  recommended  the  fastening  of  the  patella  with  pegs  as 
a  means  of  counteracting  muscular  cramp.  He  asked  Dr.  Kiedinger  whether  the 
sloughing  in  the  cases  to  which  he  referred  affected  the  entire  thickness  of  the 
soft  parts.    Dr.  Riedinger  replied  that  it  did. 

Dr.  von  Langenbeck  had  as  yet  never  seen  sloughing  of  the  flap.  In  reply 
to  Dr.  Thiersch's  suggestion  of  fastening  the  patella,  he  said  that  he  attributed 
the  muscular  spasms  to  the  flexors  rather  than  to  the  extensor  quadriceps.  He 
used  antiseptic  dressing  in  the  after-treatment,  but  it  did  not  entirely  prevent 
muscular  twi tellings. 

Dr.  Roser  (Marburg)  had  done  disarticulation  at  the  knee  four  times  without 
one  death. — London  Med.  Record,  May  15,  1878. 

Epicondylar  Fractures  of  the  Humerus. 
In  the  Allgemeine  Wiener  ATedizinische  Zeitung  for  February,  Dr.  E.  Zuck- 
erkandl  says  that  the  epicondyles,  internal  and  external,  or,  as  we  should  call 
them,  epitrochlea  and  epicondyle,  or  internal  and  external  condyle,  are,  when 
fractured,  much  more  frequently  observed  in  the  living  subject  than  the  dead,  as 
patients  incurring  such  injury  usually  recover.  Preparations  are  very  rare.  No 
drawing  of  one  is  to  be  found  in  Malgaigne's  atlas,  and,  referring  to  the  matter  in 
the  text,  Malgaigne  writes  as  follows:  k'  Some  modern  writers  have  also  spoken  of 
a  fracture  not  extending  into  the  joints  and  only  affecting  the  small  projection  of 
the  epicondyle  ;  but,  as  yet,  no  one  has  cited  an  example  of  it."  Gurlt  can  only 
discover  one  example  of  fracture  of  the  internal  condyle,  which  is  in  the  Wiirz- 
burg museum.  Hamilton  has  seen  no  specimens  of  epicondylar  fracture,  and 
does  not  think  it  possible  to  diagnose  the  existence  of  a  fracture  of  the  external 
epicondyle,  and  even  doubts  its  occurrence.  Before  describing  two  cases  which 
came  under  the  author's  notice,  one  of  the  external  and  the  other  of  the  internal 
epicondyle,  Dr.  Zuckerkandl  refers  to  the  anatomical  peculiarities  of  the  lower 
end  of  the  humerus,  that  it  is  formed  by  the  synostosis  of  five  centres  of  ossifica- 
tion, the  diaphysis,  namely,  which  includes  the  supratrochlear  fossa,  a  portion  of 
the  eminentia  capitata  on  the  ulnar  side,  and  behind,  a  part  of  the  trochlea ; 
second,  the  trochlea;  third,  the  eminentia  capitata;  fourth  and  fifth,  the  epicon- 
dyles themselves. 

The  projection  of  bone  above  the  trochlea,  serving  for  origin  to  flexor  muscles, 
is,  in  the  adult  humerus,  called  internal  epicondyle,  but  its  development  shows  it 
to  be  composed  in  part  by  the  shaft,  and  in  part  by  the  separate  centre  for  the 
epicondyle  proper,  so  that  true  epicondylar  fracture  or  separation  can  only  occur 
in  the  young  person.  The  projection  readily  felt  on  the  outer  side,  and  called 
external  epicondyle  in  the  adult,  is  in  reality  the  termination  of  the  ridge  of  the 
shaft,  on  which  posteriorly  the  centre  and  the  external  epicondyle  unite. 

The  first  case  described  by  the  author  was  a  separation  of  the  internal  epicon- 
dyle in  a  fully  developed  man.  On  examination  after  dissection  the  injury  proved 
to  be  a  true  epiphysary  disjuncture,  united  by  fibrous  material  to  the  shaft.  The 
other  case  was  one  of  fracture  of  the  external  epicondyle,  and  was  also  observed 
iu  an  adult,  but  here  there  was  a  greater  amount  of  separation,  and  less  firm 
union  of  the  fragment.  The  author  gives  figures  which  show  that  his  cases  were 
really  epiphysary  fractures  or  separations,  and  he  adverts  to  Rumbaud  and  Reg- 
nault's  views  as  to  the  tardy  union  of  these  apophyses  with  the  shafts  in  some 
cases. — London  Med.  Record,  May  15,  1878. 


1878.]  Ophthalmology  and  Otology.  279 


Intermittent  Hydarthrosis  of  the  Knee. 
M.  Panas  related  to  the  Societe  de  Chirurgie  (Union  Med.,  April  9  ;  Gaz. 
Med.,  April  20)  a  case  of  double  hydarthrosis  of  the  knee,  of  a  type  of  which  he 
had  never  previously  met  with  an  example.  It  is  not  one  of  those  recurring 
hydarthroses  which  return  at  variable  epochs  under  the  influence  of  the  same  spe- 
cial cause  which  gave  rise  to  the  first  attack,  but  puts  on  an  intermittent  form  as 
regular  as  that  observed  in  intermittent  fever.  The  subject  is  a  woman  twenty- 
two  years  of  age,  exempt  from  rheumatism,  scrofula,  or  syphilis,  who  at  the  age 
of  seventeen  was  delivered  of  an  infant  at  full  time  and  in  good  health.  A  fort- 
night afterwards  she  was  seized  suddenly  with  an  indolent  form  of  hydarthrosis 
in  both  knees,  the  fluid  effused  being  sufficient  to  raise  the  patella?  very  distinctly. 
This  state  of  things  lasted  four  days,  when  it  all  disappeared.  A  fortnight  later 
to  the  day  (always  a  Monday)  the  hydarthrosis  again  appeared,  and  lasted  again 
four  days ;  and  so  the  affection  kept  on  alternating  during  four  years  with  the 
greatest  exactitude.  Twice  during  this  time  she  became  pregnant,  once  going  to 
the  full  time,  and  once  aborting,  and  on  each  occasion  until  delivery  was  accom- 
plished the  attacks  were  suspended,  to  recur  after  it  at  the  same  intervals  as  before. 
Of  late  they  have  continued  longer,  lasting  a  full  week.  During  this  long  period 
all  kinds  of  treatment  had  been  tried  without  avail.  When  M.  Panas  admitted 
the  patient  into  the  hospital  he  was  disposed  to  doubt  her  story  ;  but  he  has  since 
witnessed  three  of  the  attacks.  Independently  of  the  attacks,  the  joints  seemed 
to  have  nothing  the  matter  with  them  beyond  a  scarcely  perceptible  thickening 
around  the  synovial  culs-de-sac,  their  movements  being  quite  normal.  Quinine 
and  all  other  means  have  proved  of  no  utility.  M.  Le  Dentu  remembers  to  have 
seen  a  somewhat  similar  case  in  Voillemier's  service,  occurring  in  the  person  of 
a  young  man,  the  hydarthrosis  coming  on  every  fortnight  and  lasting  four  or  five 
days.  In  this  case  only  one  knee  was  affected,  and  the  attacks  came  on  with  less 
regularity  than  in  the  case  of  M.  Panas.  After  quinine  and  other  remedies  had 
completely  failed,  Voillcmier  practised  transcurrent  cauterization  over  the  joints 
and  kept  the  limb  immovable  ;  and  the  patient  was  dismissed,  at  all  events  tem- 
porarily cured. 

M.  Verneuil  stated  that  he  had  met  with  a  case  at  the  Lariboisiere  exactly 
similar  to  those  narrated,  occurring  in  a  young  woman  who  had  to  be  dismissed 
uncured.  About  ten  years  ago,  also,  he  was  consulted  by  a  wealthy  gentleman 
from  the  country  who  had  suffered  from  the  affection  during  several  years. 
He  had  formerly  applied  to  Nelaton,  who  told  him  that  so  rare  was  his  com- 
plaint that  he  had  only  once  before  met  with  an  example.  Quinine  was  given, 
and  a  cure  effected  which  held  good  for  six  years.  When  he  came  to  M.  Ver- 
neuil, the  intermittent  hydarthrosis  had  returned  for  about  a  year,  and  quinine 
had  been  again  resorted  to,  but  without  any  effect.  Energetic  compression  was 
methodically  employed,  but  the  patient  did  not  return. — Med.  Times  and  Gaz., 
May  4,  1878. 


OPHTHALMOLOGY  AND  OTOLOGY. 

Transverse  Calcareous  Film  of  the  Cornea. 
Mr.  Edward  Nettleship  read  a  paper  on  this  subject  at  a  late  meeting  of 
the  Royal  Medical  and  Chirurgical  Society  (Lancet,  May  4,  1878).    The  disease, 
a  somewhat  rare  one,  has  been  described  by  various  authors,  but  chiefly  in  its 
local  relations.    The  chief  objects  of  the  paper  are  to  draw  attention  to  some 


280 


Progress  of  the  Medical  Sciences. 


[July 


points  in  the  natural  history  of  the  disease  which  may  throw  light  on  its  causation, 
and  to  confirm  the  statements  of  earlier  writers,  especially  Dixon  and  Bowman, 
as  to  the  good  results  of  local  treatment  in  suitable  cases.  A  thin  film  of  crystal- 
line, chiefly  calcareous,  substance  is  formed  beneath  the  anterior  corneal  epithelium ; 
it  can  be  chipped  off  in  little  flakes,  leaving  the  underlying  cornea  clear.  It  is 
limited  to  the  parts  habitually  uncovered  by  the  lids,  and  when  complete  it  forms 
a  broad,  nearly  transverse  stripe,  terminating  at  each  end  a  little  within  the  lateral 
boundaries  of  the  cornea.  The  symptoms,  as  a  rule,  are  very  slight,  and  there 
are  generally  no  complications,  even  when  the  disease  is  of  many  years'  standing  ; 
but  sometimes  chronic  iritis  and  glaucoma  come  on,  and  occasionally  ulceration 
takes  place  on  the  diseased  patch.  It  seldom  begins  in  both  eyes  at  the  same 
time,  but  is  almost  invariably  symmetrical  in  the  end.  The  film  is  formed  slowly, 
and  may  continue  to  increase  for  some  years.  The  disease  is  one  of  middle  and 
advanced  life,  and  its  subjects,  almost  without  exception,  are  males.  Occupation 
seems  to  have  no  direct  influence.  The  morbid  tendencies  of  the  patients,  so  far 
as  they  are  at  present  known,  lead  the  author  to  suggest  that,  in  regard  to  causa- 
tion, excess  of  uric  acid  in  the  blood  furnishes  the  most  likely  explanation  from 
the  constitutional  side,  though  local  peculiarities,  not  at  present  understood,  are 
necessary  as  determining  causes.  Several  new  cases  with  naked-eye  and  micro- 
scopic drawings  are  given.  The  paper  is  supplemented  by  abstracts  of  all  the 
published  cases  (fifteen  in  number)  known  to  the  author,  and  in  some  of  these 
(recorded  some  years  ago  by  Mr.  Fairlie  Clarke)  the  present  condition  of  the 
patients  has  been  ascertained. 

Mr.  Power  thought  most  of  the  cases  were  referable  to  the  gouty  diathesis, 
the  corneal  opacity  being  also  associated  with  accumulation  of  white  matter 
along  the  borders  of  the  lids.  At  the  same  time  exposure  to  irritants  might 
determine  the  corneal  change.  In  several  cases  he  had  chipped  off  the  thin  film 
by  means  of  a  cataract  knife.  Mr.  Hutchinson  did  not  think  the  affection 
was  so  directly  connected  with  the  gouty  diathesis  as  Mr.  Power  implied,  and  the 
first  case  he  saw  was  one  under  the  care  of  Messrs.  Bowman  and  Dixon,  and  re- 
ferred to  by  Mr.  Nettleship  in  the  paper.  That  case  was  at  first  thought  to  be 
gouty.  Since  then  he  had  seen  only  two  or  three  cases,  and  had  not  found  them 
associated  with  gout.  He  suggested  that,  of  predisposing  causes,  senility  took 
first  rank,  and  next,  perhaps,  gout,  whilst  no  doubt  other  contributing  causes, 
such  as  exposure  to  irritants,  nerve-disorders,  etc.,  might  be  present.  He  con- 
trasted the  condition  in  these  respects  with  Dupuytren's  contraction  of  the  palmar 
fascia,  which  may  be  a  senile  change,  or  associated  with  gout,  or  induced  in  pre- 
disposed subjects  by  local  inflammation,  and  he  inquired  whether  this  palmar 
fascial  contraction  was  met  with  by  Mr.  Nettleship  in  many  of  his  cases.  Mr. 
Nettleship,  in  reply,  was  interested  to  hear  that  Mr.  Power  had  seen  several 
cases  of  this  affection.  In  none  of  his  cases  had  he  been  aware  of  the  presence 
of  the  condition  of  the  palmar  fascia  referred  to  by  Mr.  Hutchinson,  but  he  had 
not  sought  for  it.  Certainly  it  was  never  present  so  as  to  give  rise  to  any  dis- 
comfort. Since  his  paper  was  sent  in  he  had  seen  another  case  in  a  female,  and 
in  this  case  only  one  eye  was  affected,  although  it  had  lasted  for  forty  years.  The 
patient  was  not  gouty,  but  the  urine  was  habitually  loaded  with  lithates. 

Removal  of  Piece  of  Iron  from  the  Lens  by  means  of  a  Magnet. 
At  a  late  meeting  of  the  Clinical  Society  of  London  (Lancet,  March  30,  1878), 
Mr.  McHardy  read  notes  of  a  case  of  removal  of  a  chip  of  iron  from  the  crystal- 
line lens  by  means  of  a  powerful  magnet.  The  patient,  thirty-one  years  of  age. 
when  at  work,  was  struck  in  the  eye  by  a  fragment  of  steel  from  the  hammer  he 
was  using.    When  seen,  twenty-four  hours  after,  there  was  evidence  of  com- 


1878.] 


Ophthalmology  and  Otology. 


281 


mencing  iritis  ;  there  was  nothing  in  the  vitreous  ;  the  eye  was  less  painful  than 
on  the  night  of  the  accident ;  its  tension  normal.  Atropine  drops  were  pre- 
scribed. The  next  day  there  was  no  pain,  and  less  congestion  of  the  eye ;  the 
pupil  was  well  dilated,  and  allowed  of  detection  of  a  sharply  defined  opacity  on 
the  anterior  surface  of  the  lens  in  a  downward- inward  direction  from  the  centre, 
the  peripheral  end  being  nearer  to  the  margin  of  the  dilated  pupil.  The  cornea 
was  almost  normal.  The  atropine  was  continued,  and  absolute  rest  enjoined. 
The  removal  of  the  chip  appeared  to  be  imperative,  lest  it  should  gravitate  down- 
wards ;  at  the  same  time  Mr.  McHardy  was  unwilling  to  remove  the  lens,  and 
he  also  thought  if  it  were  injured  by  the  forceps  it  would  not  be  easy  to  tell  if  any 
subsequent  opacity  of  the  lens  were  due  to  the  original  injury  or  to  the  operation. 
He  therefore  had  a  magnetic  spatula  constructed  by  Messrs.  Weiss,  intending  to 
use  it  in  connection  with  an  electro-magnet.  On  Mr.  B.  Carter's  suggestion, 
the  procedure  was  modified  by  employing  a  powerful  bar  magnet  connected  with 
two  Grove's  cells.  Gradually  approaching  it  to  the  front  of  the  cornea,  when  it 
was  four  inches  away  the  chip  sprang  from  the  lens  to  the  inner  surface  of  the 
cornea,  and  fell  into  the  anterior  chamber,  whence  it  was  removed,  together  with 
a  small  portion  of  iris.  A  patch  of  opacity  exactly  corresponding  in  size  to  the 
chip  was  left  on  the  lens.  Subsequently  a  cataract  formed,  and  the  injured  lens 
became  absorbed.  The  patient's  vision,  aided  by  a  lens  of  twelve  dioptrics,  is 
normal  for  distant  objects.  Mr.  McHardy  acknowledged  his  indebtedness  to  Mr. 
Ladd  and  Dr.  Tibbits  for  assistance  and  suggestions,  and  he  referred  to  a  paper 
by  Dr.  McKeown  in  the  Dublin  Journal  of  Medical  Science  for  September, 
1876,  where  three  or  four  cases  are  recorded  of  the  use  of  magnets  in  the  removal 
of  fragments  of  steel  in  the  eye. 

Mr.  Brudenell  Carter,  having  seen  the  case,  stated  that  the  position  of 
the  fragment  was  such  that  any  other  attempt  at  its  removal  would  have  jeopard- 
ized the  eye.  If  nothing  had  been  done,  the  fragment  would  probably  have 
fallen  below  the  iris,  and  would  have  set  up  destructive  inflammation  ;  and  any 
attempt  at  its  removal  by  forceps  would  certainly  have  injured  the  lens.  By 
withdrawing  it  from  its  bed  and  bringing  it  to  the  front  of  the  iris,  the  magnet 
had  obviated  these  difficulties. 

Causes  of  Myopia. 

At  the  International  Medical  Congress  in  1877,  M.  Hattenhoff  reported  as 
follows  on  the  etiology  of  myopia.  1.  The  ordinary  causes  of  myopia  are  heredity 
and  ocular  work,  combined  or  singly.  2.  Hypermetropia  can  be  changed  into 
myopia  by  ocular  work.  3.  The  progress  of  civilization,  and  especially  of  edu- 
cation, tends  to  increase  the  amount  of  myopia.  4.  The  predisposition  to  acquired 
myopia  is  often  hereditary.  5.  In  ocular  work  three  factors  are  principally  con- 
cerned in  producing  myopia — accommodation,  convergence  of  visual  axes,  and 
oculo-cephalic  congestion.  6.  The  conditions  of  age,  circumstances,  duration  of 
work,  nature  of  objects  viewed,  and  state  of  visual  apparatus,  powerfully  influence 
the  development  of  myopia.  7.  The  prophylaxis  of  myopia  includes  individual 
hygienic  measures  at  school  and  at  home,  which  are  in  great  part  realizable  by 
the  united  efforts  of  physicians  and  authorities.  Among  these  measures  may  be 
reckoned  the  use  of  convex  glasses  for  hypermetropes. — London  Med.  Record, 
March  15,  1878. 

Amyl-Nitrite  in  Tinnitus  Aurum. 
Michael  (ArcJiiv  fur  Ohrenheilkunde)  has  found  more  or  less  improvement 
in  nineteen  out  of  thirty-three  cases.    In  all  cases  in  which  benefit  was  derived 


282 


Progress  of  the  Medical  Sciences. 


[July 


there  was  increase  of  the  tinnitus  during  the  inhalation,  and  decrease  with  the  dis- 
appearance of  the  flushing  of  the  face  from  the  amyl-nitrite.  Weber  Liel  obtained 
improvement  in  two.  Urbantschitsch  also  found  improvement  in  one  case.  The 
last-named  gentleman  saw  the  inhalations  followed  by  collapse  of  some  minutes' 
duration,  and  by  hemiplegia  of  a  very  short  duration.  He  advises  the  use  of 
only  one  drop  at  first,  either  pure  or  mixed  with  alcohol,  and  suspends  the 
application  after  a  few  inhalations,  as  the  action  of  the  drug  increases  for  several 
seconds,  and  may  come  on  very  suddenly. — London  Med.  Record,  March  15, 
1878. 


MIDWIFERY  AND  GYNAECOLOGY. 

Normal  Pregnancy  and  Accouchement  during  an  Extra-Uterine  Pregnancy  of 
Seven  Years'  Duration. 

This  somewhat  rare  combination  of  circumstances  has  been  observed  and  re- 
corded by  Madame  Rampin,  an  obstetric  practitioner  in  Toulon.  In  1870  Marie 
C,  who  had  had  a  natural  accouchement  two  years  previously,  presented  all  the 
signs  of  another  pregnancy — suppression  of  the  menses,  turgescence  of  the  breasts, 
progressive  enlargement  of  the  abdomen,  etc.  Several  months  later  she  was 
seized  with  acute  pains  resembling  those  of  labour,  but  her  attendants,  after  vagi- 
nal examination,  declared  that  there  was  no  pregnancy.  These  pains  lasted 
three  days,  when  they  gradually  passed  off.  At  the  end  of  six  months  the 
menses  reappeared,  the  swelling  of  the  abdomen  fell  considerably,  and  became 
almost  painless,  and,  with  the  exception  that  there  was  slight  prolapsus  uteri  and 
a  sense  of  weight  in  the  right  iliac  fossa,  the  patient  enjoyed  comparatively  good 
health.  In  1875  she  again  became  pregnant,  and,  after  a  natural  labour  of  three 
hours,  was  delivered  of  a  living  child.  Madame  R.  then  took  advantage  of  the 
fiaecidity  of  the  abdominal  walls  to  make  a  careful  examination  of  the  tumour, 
and  was  so  enabled  to  diagnose  positively  the  existence  of  extra-uterine  preg- 
nancy. In  the  beginning  of  1877  Marie  C.  died  of  phthisis.  At  the  autopsy 
was  found,  in  the  right  Fallopian  tube,  a  full-grown  foetus,  mummified,  and  en- 
closed in  a  firm,  dense  sac. — Glasgow  Med.  Journal,  May,  1878,  from  Lyon 
Me'dical,  Nov.  25,  1878. 

» 

Traction  of  the  Lower  Jaw  in  Head-last  Cases. 
Dr.  Matthews  Duncan,  at  a  late  meeting  of  the  Obstetrical  Society  of 
London  (British  Med.  J  own.,  May  4,  1878)  contributed  a  paper  on  this  subject. 
He  commenced  by  saying  that  by  the  traction  referred  to  two  objects  were  pro- 
fessed to  be  gained — flexion  of  the  head  and  extraction.  Attempts  to  secure 
these  objects  by  the  fingers  applied  to  the  fossa?  caninae  were  in  vain,  because  the 
force  in  a  right  direction  available  by  such  procedure  was  of  too  small  amount. 
Besides  fraction  of  the  lower  jaw,  there  were  two  other  sources  of  power :  first, 
pulling  by  the  feet  or  otherwise  through  the  spine  ;  this  was  the  paramount 
force:  second,  expression,  which,  by  mere  strength  of  the  accoucheur's  arm, 
might  be  estimated  as  from  30  to  40  pounds,  or,  using  the  weight  of  the  accou- 
cheur's body,  might  rea  jh  100  pounds.  The  dangers  attending  spinal  pulling  and 
expression  were  very  considerable.  Those  of  the  latter  method  were  as  yet  but 
little  known.  Danger  in  head-last  cases,  where  the  base  of  the  skull  was  in  the 
brim  of  the  pelvis,  was  not  from  compression  of  the  cord,  but  from  asphyxia  and 
from  inhalation  of  solid  and  fluid  matters  into  the  lungs.    Speedy  delivery  was 


1878.] 


Midwifery  and  Gynaecology. 


283 


often  desirable,  and  lower  jaw  traction  deserved  consideration  when  there  was 
obstruction  requiring  the  use  of  force,  and  when  the  other  forces  were  not  suffi- 
cient. Injuries  resulted  in  two  of  Dr.  Duncan's  four  experiments  with  lower  jaw 
traction  ;  separation  of  the  two  halves  of  the  bone  in  one  case  in  which  58  pounds 
were  suspended  on  it,  and  laceration  of  the  inside  of  the  mouth  with  distortion  in 
another.  The  force  applied  through  the  lower  jaw,  acting  as  it  did  chief!  y 
through  the  maxillary  joints,  was  favourably  applied  for  producing  extraction, 
but  not  for  producing  flexion,  because  of  the  nearness  of  the  joint  to  the  centre  of 
the  head's  motion,  the  bitemporal  diameter  (in  a  contracted  brim).  The  whole 
force  so  applicable  might  be  more  than  58  pounds,  and  might  certainly  all  be 
used  in  cases  of  dead  children,  or  children  certainly  doomed  to  death,  or  in  cases 
where  the  head  was  left  in  utero.  Further  experience  was  required  to  show  how 
much  could  be  safely  used  in  a  living  foetus.  Lower  jaw  traction  did  not  produce 
considerable  flexion  of  the  head.  Flexional  efforts  were  seldom  required.  The 
paramount  dragging  by  the  spine,  as  it  acted  in  a  case  of  contracted  brim  behind 
the  centre  of  the  head's  motion,  annulled  or  undid  any  slight  flexion  produced  by 
the  lower  jaw  traction.  But  spinal  pulling  could  easily  be  made  to  produce 
flexion  after  the  head's  passage  of  the  brim  by  giving  it  a  proper  direction ;  and 
at  this  time  flexion  was  essential. 

Causes  of  Puerperal  Poisoning. 

In  a  lecture  at  the  Maternite  (Gaz.  des  Hop.,  April  18),  on  "  Some  of  the 
Causes  of  Puerperal  Intoxication,"  Dr.  "Hervieux,  after  alluding  to  the  reality 
of  contagion,  observed  that  another  well-marked  cause  was  overcrowding  (encom- 
bremeni),  as  shown  by  the  different  mortality  observed  in  hospital  and  town  prac- 
tice. Of  the  operation  of  this  cause  he  had  had  frequent  proofs  at  the  Maternity  ; 
for  although  M.  Besnier,  in  his  reports  on  the  Paris  hospital  mortality,  shows  that 
for  more  than  ten  years  the  sanitary  state  of  the  Maternite  has  been  excellent,  this 
is  entirely  dependent  upon  the  condition  that  all  the  beds  of  a  ward  shall  not  be 
occupied.  Whenever,  from  circumstances,  this  condition  has  not  been  observed, 
puerperal  accidents  of  more  or  less  severity  have  invariably  manifested  themselves 
within  from  twenty-four  to  forty-eight  hours.  On  the  other  hand,  whenever  the 
patients  are  isolated,  a  notable  amelioration  of  their  condition  is  as  invariably  pro- 
duced ;  as  is  also  the  case  when  a  patient  is  taken  from  a  crowded  place  to  one 
that  is  not  so.  We  may  establish  a  fundamental  distinction  between  the  effects  of 
overcrowding  and  contagion.  To  overcrowding  Dr.  Hervieux  attributes  the  gene- 
rative power,  and  to  contagion  the  propagative  power.  This  opinion  is  quite  as 
admissible  as  the  theory  of  germs  ;  for  germs  exist  everywhere,  while  puerperal 
poisoning  does  not  prevail  everywhere.  Overcrowding  only  exists  in  certain 
restricted  localities,  and  it  is  in  such  that  puerperal  epidemics  arise. 

Another  cause  of  propagation  is  the  practice  of  post-mortem  examinations. 
When,  in  I860,  M.  Hervieux  assumed  the  direction  of  the  Maternite,  imbued 
with  the  doctrines  generally  admitted  at  that  period,  he  believed  in  the  existence 
of  an  essential  fever  of  a  most  mysterious  and  impenetrable  origin,  and  pursued 
post-mortem  examinations  with  ardour.  But  the  more  laboriously  he  worked  in 
this  direction,  the  more  violent  were  the  epidemics  which  broke  out  in  the  wards. 
In  the  belief  that  the  autopsies  might  have  something  to  do  with  this  frightful 
mortality,  he  abandoned  their  performance,  and  a  sensible  amelioration  ensued. 
But  other  reforms  having  been  put  into  force  at. the  time  of  the  autopsies  being 
given  up,  he  thought  that  possibly  he  might  have  been  mistaken  in  attributing 
these  ill  effects  to  them.  He  accordingly  resumed  them  ;  but  although  they  were 
accompanied  by  every  available  precaution,  new  catastrophes  followed  their  re- 
sumption, as  they  also  did  on  other  occasions,  when,  at  the  solicitation  of  his 


284 


Progress  of  the  Medical  Sciences. 


[July 


internes  he  had  sanctioned  them.  The  statistics  of  Prof.  Spaeth,  of  Vienna,  quite 
confirm  this  view  of  the  poisonous  effects  of  post-mortems  ;  for  while  at  the  mater- 
nity of  that  city,  where  there  are  medical  students,  the  deaths  were  5.32  per  cent., 
at  the  maternity  for  midwives  they  were  only  3.4  7,  the  practising  of  autopsies  being 
the  only  difference  in  the  conditions  of  the  two  establishments. 

M.  Hervieux  does  not  believe  in  the  existence  of  true  epidemic  constitution  as 
regards  puerperal  disease.  There  are,  in  fact,  no  puerperal  epidemics  in  the  lite- 
ral sense  of  the  word,  it  being  entirely  a  question  of  locality.  This  is  seen  by  the 
statistics  of  puerperal  mortality  occurring  in  the  different  hospitals  of  Paris  during 
1873-1876,  showing  that  no  parallelism  whatever  exists.  For  example,  in  1873, 
while  at  St.  Antoine,  it  was  6.56  per  cent.,  8.65  at  Les  Cliniques,  8.88  at  the 
H6tel-Dieu,  and  9.81  at  the  Neckar,  it  was  only  3.19  at  La  Charite,  2.91  at 
Beaujon,  2.38  at  St.  Louis,  2.09  at  the  Pitie,  and  1.93  at  the  Maternity,  and  at 
the  bureaux  de  bienfaisance  it  was  only  0.29,  and  at  the  residence  of  midwives 
0.93.  These  so-called  epidemics  are  all  questions  of  locality,  independent  of 
atmospheric  vicissitudes,  ozone,  electricity,  direction  of  winds,  etc.  They  are 
dependent  on  the  measures  of  internal  organization,  hospital  hygiene,  and  per- 
sons ;  and  these  causes,  so  far  from  being  occult  and  mysterious,  and  beyond  our 
comprehension,  are  material,  comprehensible,  and  removable.  The  following  are 
the  rules  which  Dr.  Hervieux  has  followed  since  his  appointment  to  the  Maternity, 
and  by  the  observation  of  which  he  has  secured  such  favourable  conditions:  1. 
Surround  the  accoucMes  by  plenty  of  space,  disseminating  them  as  much  as  pos- 
sible. 2.  Spare  them  all  examinations  that  are  not  rigorously  necessary.  3. 
Isolate  accoucMes  who  are  ill  from  those  who  are  well ;  and  those  of  them  who 
are  dangerously  ill  from  those  who  are  only  slightly  so.  4.  Suppress  all  autop- 
sies. 5.  Prefer  to  the  alternate  occupation  of  the  wards  their  continuous  occupa- 
tion, with  as  much  dispersion  of  patients  as  possible.  6.  Appoint  special  attend- 
ants for  those  who  are  dangerously  ill.  7.  Whenever  an  epidemic  seems  about 
to  manifest  itself,  restrict  the  admissions,  or  even  close  the  service. — Med.  Times 
and  Gaz.,  May  18,  1878. 

Treatment  of  Sore  Nipples. 
Dr.  Haussmaxx  (Berlin.  Klin.  Wochenschrift,  Xo.  14)  recommends  the 
application  of  a  five  per  cent,  solution  of  carbolic  acid  for  producing  a  speedy  cure 
of  fissured  nipples  occurring  in  women  after  confinement.  He  reports  a  case  in 
which  both  nipples  being  thus  affected  suckling  was  almost  impossible.  Nitrate 
of  silver  and  lead  lotion  had  been  applied  in  vain  to  several  small  ulcers  and 
numerous  fissures.  Strips  of  linen,  saturated  with  the  carbolic  acid  solution,  were 
then  oi-dered  to  be  placed  over  the  nipples,  and  renewed  every  two  or  three 
hours  ;  the  dressing  being  removed  and  the  parts  carefully  cleaned  before  the 
child  was  put  to  the  breast.  The  first  application  was  followed  by  considerable 
diminution  of  the  pain  ;  on  the  following  day  the  fissures  were  found  to  be  reduced 
in  size,  and  the  excoriations  had  disappeared.  Two  days  afterwards  the  woman 
was  able  to  suckle  her  child  without  difficulty,  the  fissures  having  completely 
healed,  and  there  was  no  return  of  the  symptoms.  In  another  case  a  weaker  solu- 
tion was  tried,  but  the  effect  was  not  satisfactory.  A  few  applications  of  the  five 
per  cent,  solution  sufficed  to  produce  a  cure.  The  acid  causes  less  pain  than 
nitrate  of  silver. — Med.  Examiner,  April  25,  1878. 

Rheumatoid  Inflammation  of  the  Joints  in  Women. 

Mr.  Davies  Colley,  Senior  Assistant  Surgeon  to  Guy's  Hospital,  narrates 
(Obstetrical  Journal  of  Great  Britain,  June,  1878)  six  cases  of  what  he  con- 


1878.] 


Midwifery  and  Gynaecology. 


285 


aiders  a  definite  joint- disease  characterized  by  great  pain  and  tenderness,  and 
more  especially  by  redness  and  oedema  of  the  soft  parts  in  the  neighbourhood.  It 
is  accompanied  in  the  earlier  stages  by  febrile  disturbance,  which,  however,  I 
have  never  noticed  to  be  considerable.  Usually  a  mild  attack  is  noticed  in  other 
joints  before  the  inflammation,  so  to  speak,  concentrates  itself  in  one  particular 
locality.  The  diseases  with  which  it  may  be  confounded  are  erysipelas,  phlebitis, 
or  acute  suppuration  of  the  joint.  In  the  latter  case  the  mistake  might  lead  to 
serious  consequences.  The  surgeon  might  be  induced  to  make  a  free  incision, 
and  thus  convert  an  inflammation  which  would  have  undergone  resolution  into  a 
lingering  suppuration.  From  most  cases  of  erysipelas  the  absence  of  vesication 
and  a  high  temperature  would  form  a  sufficient  means  of  discrimination.  From 
phlebitis  the  absence  of  the  cord-like  induration  of  the  veins  would  probably  en- 
able us  to  diagnose  it,  although  the  oedema  in  some  of  my  cases  resembled  very 
much  that  which  accompanies  thrombosis.  If  I  may  form  an  opinion  from  the 
limited  experience  I  have  had,  the  prognosis  is  so  far  favourable  in  that  the  in- 
flammation will  probably  go  away  without  suppuration.  The  joint  will,  however, 
remain  more  or  less  bound  by  fibrous  adhesions  ;  so  the  patient  must  expect  some 
impairment  of  the  usefulness  of  the  limb.  As  I  have  never  had  an  opportunity 
of  examining  the  condition  of  the  joint  after  death  or  amputation,  I  cannot  speak 
with  confidence  upon  the  pathological  character  of  the  affection.  Judging  from 
the  absence  of  fluctuation  in  most  of  my  cases,  and  the  presence  of  superficial 
oedema,  I  have  been  led  to  think  that  the  chief  seat  of  inflammation  is  in  the 
fibrous  capsule  of  the  joint  rather  than  in.  the  synovial  membrane.  If  the  latter 
had  been  primarily  affected,  I  should  have  looked  for  effusion  inside  the  articula- 
tion, and  consequent  fluctuation  as  in  the  ordinary  form  of  synovitis. 

With  respect  to  the  causation  of  the  disease,  it  will  be  observed  that  in  all  the 
cases  reported  or  mentioned  there  was  reason  to  suspect  uterine  or  vaginal  irrita- 
tion. Some  had  severe  leucorrhoea ;  others  were  pregnant,  and  of  these  all  but 
one  for  the  first  time.  In  two  cases  there  was  no  statement  as  to  pregnancy,  but 
as  they  had  been  married  a  short  time  previously,  it  is  probable  that  either  preg- 
nane}', vaginal  discharge,  or  frequent  sexual  congress  was  the  source  of  irritation. 

I  have  said  before  that  I  have  not  seen  such  a  disease  in  the  male.  The  only 
exception  I  would  make  to  this  statement  is  in  the  case  of  carpal  and  tarsal  dis- 
ease. Here  there  is  often  much  redness  and  oedema  as  well  as  acute  pain,  and 
such  inflammations,  without  suppuration,  are  not  infrequent  in  the  gouty  and 
rheumatic  of  both  sexes.  Moreover,  I  have  never  seen  a  case  of  joint  affection 
like  those  I  have  narrated  in  the  female,  except  when  there  was  evidence  of  some 
vaginal  or  uterine  irritation. 

It  may  be  alleged  that  these  inflammations  are  merely  examples  of  gonorrhoeal 
synovitis  in  the  female,  and  I  am  disposed  to  admit  that  there  is  some  alliance 
between  the  two  affections  in  respect  to  their  reflex  origin  through  the  nervous 
system.  In  the  male,  however,  we  rarely  see  any  other  joint  affected  than  the 
knee,  and  the  disease  resembles  an  ordinary  synovitis.  In  the  women  whose 
cases  I  have  narrated,  the  elbow  was  quite  as  often  affected  as  the  knee.  There 
was,  moreover,  great  oedema  and  redness,  with  little,  if  any,  effusion  into  the 
joints.  The  subsequent  history  was  also  unlike  what  is  observed  in  gonorrhoeal 
rheumatism.  I  cannot  lay  much  stress  upon  the  absence  of  a  history  of  vaginal 
discharge  in  most  of  my  cases,  as  probably  no  questions  were  asked  upon  the 
point,  and  even  if  there  had  been,  the  answers  would  not  be  reliable,  unless  an 
examination  had  been  made. 

If  it  is  supposed  that  there  was  some  vaginal  discharge  in  each  of  the  cases, 
which  gave  rise  to  the  joint  inflammation,  it  can  hardly  have  been  an  accidental 
coincidence  that  so  large  a  proportion  of  them  should  have  occurred  in  pregnant 


28G  Progress  of  the  Medical  Sciences.  [July 


women.  I  cannot  find  that  works  upon  midwifery  make  any  mention  of  the  lia- 
bility during  pregnancy  to  such  affections.  Nevertheless,  the  facts  which  I  have 
brought  forward  seem  to  show  that  pregnancy  either  directly  caused  the  inflam- 
mation by  some  influence  reflected  upon  the  vaso-motor  system,  or  indirectly  as- 
sisted in  its  development  in  a  patient  suffering  from  gonorrhoea  or  leucorrhoea,  by 
the  debility  due  to  the  pregnant  condition. 

Nigrinism. 

The  above  is  selected  from  a  large  choice  of  names  to  indicate  a  condition  the 
reverse  of  that  which  obtains  in  albinoes.  Woronichin  (Jahrbuch  fur  Kindtr- 
heilkunde,  Band  xi.,  Heft  iv.)  relates  several  cases  of  more  or  less  complete 
nigrinism,  of  which  the  following  is  the  most  remarkable.  A  married  couple, 
both  slightly  dark,  had  had  two  ordinary  children,  when  the  woman  again  be- 
came pregnant.  Nothing  unusual  occurred  while  she  was  in  this  condition, 
and  after  an  easy  labour  she  gave  birth  to  a  girl,  whose  blackness  struck  all 
present  with  astonishment.  The  midwife  gently  informed  the  mother  that  the 
child  would  not  live ;  but,  as  the  child  cried  loudly  and  sucked  well,  a  medical 
man  was  hastily  called,  who  sought  in  vain  for  a  malformation  of  the  heart  or 
liver.  The  child  grew  well,  got  her  teeth  early,  soon  learnt  to  walk,  and,  in  her 
third  year,  was  extremely  lively  and  sensible.  The  skin  was  of  a  brownish- 
black  colour,  almost  darker  than  that  of  a  mulatto.  The  shape  of  the  head  and 
the  expression  were  quite  of  the  Caucasian  type,  and  had  nothing  in  common 
with  the  negro.  The  hair  was  black,  but  smooth  and  hanging — not  woolly. 
Certain  parts  of  the  skin  were  of  a  lightish  colour,  namely,  around  the  navel, 
behind  the  ears,  between  the  fingers  and  toes,  and  about  the  genitals  and  the  nos- 
trils. The  child  is  now  eight  years  of  age,  is  well  grown  and  healthy,  but  is  every- 
where known  as  Black  Mary.  Two  cases  of  partial  nigrinism  are  also  given;  but 
these  might  with  equal  justice  be  looked  upon  as  large  nsevi. — London  Med. 
Record,  March  15,  1878. 

The  Antiseptic  Method  in  Ovariotomy. 

Dr.  Carl  Schroeder,  Professor  of  Obstetrics  and  Gynajcolqgy  in  the  Uni- 
versity of  Berlin,  has  just  published  in  the  Berliner  Medicinische  Wochenschrift 
a  highly  interesting  and  valuable  communication  on  the  subject  of  ovariotomy. 
From  May  25th,  1876,  to  February  24th,  1878,  he  has  operated  in  fifty  cases, 
which  he  summarizes  in  a  table,  to  which  he  adds  comments.  From  the  total 
cases,  three  must  be  deducted  in  which  the  patients  were  the  subjects  of  cancer, 
and  died,  in  consequence  of  the  extension  of  that  disease,  on  the  tenth,  nine- 
teenth, and  forty-fifth  days  after  the  operation.  In  the  remaining  forty-seven 
cases,  there  were  seven  deaths  ;  i.  <?.,  14.9  per  cent,  of  deaths  and  85.1  of  recov- 
eries. On  dividing,  however,  the  table  into  two  equal  parts,  it  is  found  that  (ex- 
cluding the  three  cancer  cases)  the  first  twenty-four  operations  were  folloAved  by 
six  deaths  =  25  per  cent.,  and  the  last  twenty-three  by  only  one  =4.3  per  cent. 
This  great  reduction  in  the  mortality,  Dr.  Schroeder  says,  may  be  attributed  to 
improved  skill  on  the  part  of  the  operator  ;  but  he  attaches  much  greater  import- 
ance to  the  avoidance  of  infection,  which  he  regards  as  almost  exclusively  the 
cause  of  death  after  ovariotomy. 

As  regards  the  places  where  the  operations  were  performed,  thirty-three 
patients  were  operated  on  in  the  Lying-in  Institution  in  Berlin,  twelve  in  private 
houses,  and  two  in  the  Charite  Hospital.  (The  three  cases  of  cancer  all  oceurred 
in  the  Lying-in  Institution.)    Of  the  thirty-three  patients  in  the  Institution,  only 


1878.] 


Midwifery  and  Gynaecology. 


287 


one  died  =  3  per  cent.  ;  while  the  mortality  among  the  fourteen  operated  on 
elsewhere  was  six  =  43  per  cent. 

Dr.  Schroeder  says  that  the  low  death-rate  in  the  Lying-in  Institution  is  very 
remarkable,  when  the  circumstances  are  considered.  The  institution  was  origin- 
ally a  private  house ;  the  wards  are  defective  in  their  sanitary  arrangements,  and 
are  always  overcrowded  by  one-half  of  the  normal  number;  women  with  offen- 
sive discharges  are  often  admitted ;  and,  under  all  the  circumstances,  the  occa- 
sional occurrence  of  puerperal  fever  is  unavoidable  ;  and  hence  a  more  unfavour- 
able place  for  ovariotomy  could  scarcely  be  conceived.  Yet,  among  thirty-three 
patients,  there  was  only  one  death  ;  and  this  was  not  from  infection,  but  from  in- 
traperitoneal hemorrhage,  which  proved  fatal  on  the  nineteenth  day. 

The  key  to  this  success,  Dr.  Schroeder  says,  lies  in  having  so  perfect  a  control 
over  the  persons  and  instruments  concerned  in  the  operation,  that  infection  is 
warded  off  from  the  subjects  of  operation.  The  operations  are  performed  in  pri- 
vate rooms,  into  which  parturient  women  are  never  admitted,  and  suppurating 
cases  only  rarely.  The  instruments  to  be  used  are  always  freshly  cleaned  by  the 
instrument- maker,  and  allowed  to  lie  in  a  five  per  cent,  solution  of  carbolic  acid ; 
the  sponges  are  quite  new,  and  are  always  most  carefully  cleaned  and  scalded  on 
the  preceding  day  by  the  head  midwife,  and  placed  during  the  night  in  solution 
of  carbolic  acid.  At  the  operation,  five  persons  are  present  besides  the  assistant 
who  administers  chloroform.  The  operator  and  one  assistant  only  come  into  con- 
tact with  the  wound ;  a  second  assistant  has  charge  of  the  instruments  ;  the  head 
midwife  mixes  the  solutions  and  renders  occasional  assistance  ;  and  a  nurse  stands 
beside  the  operator  with  a  vessel  containing  carbolic  acid  solution.  The  head 
midwife  is  required  to  avoid  coming  into  contact  with  all  sources  of  infection  ; 
and  the  nurse  is  detailed  for  duty  in  the  ovariotomy  wards  exclusively.  Dr. 
Schroeder  and  his  assistants  take  the  greatest  pains  to  avoid  all  contact  with  in- 
fective materials. 

The  operation  is  always  performed  in  the  morning,  before  any  other  patients 
are  visited  :  at  half-past  seven  in  the  summer  ;  in  winter,  as  soon  as  it  is  suf- 
ficiently light.  On  rising,  Dr.  Schroeder  takes  a  bath,  dresses  himself  so  that 
his  clothes  may  not  convey  infection,  and  washes  in  carbolic  acid  solution  before 
proceeding  to  operate.  At  least  half  an  hour  before  the  operation,  the  carbolic 
acid  spray  is  brought  into  play  in  the  room  ;  and  then,  the  patient  having  been 
washed  in  a  pure  atmosphere,  the  operators  proceed  to  their  work  with  clean 
hands  and  clean  instruments.  These  precautions  are,  in  Dr.  Schroeder' s  opinion, 
sufficient  to  obviate  the  risk  of  peritonitis,  which,  in  its  generalized  form,  he 
holds  to  be  the  result  of  infection  and  not  of  injury. 

Even  in  the  most  severe  cases,  and  in  those  where  the  peritoneum  was  exten- 
sively interfered  with,  there  was  scarcely  any  reaction.  The  pulse,  indeed,  rose 
to  90  or  100  ;  but  the  temperature  never  exceeded  100°  Fahr.,  or  sometimes  on 
the  first  evening  100.4°  ;  not  uncommonly  it  remained  absolutely  normal.  Even 
in  one  very  difficult  case  of  suppurating  cyst  with  extensive  adhesions  (followed 
by  recovery),  the  temperature  did  not  exceed  98.8°  during  the  first  ten  days. 

In  a  foot-note,  Dr.  Schroeder  remarks  that  there  is,  as  a  rule,  a  fall  of  temper- 
ature, sometimes  as  low  as  95°  Fahr.,  immediately  after  the  operation.  This, 
however,  has  never  been  followed  by  any  ill  result.  He  has  never  seen  indica- 
tions of  carbolic  acid  poisoning,  nor  has  he  found  in  any  case  carbolic  acid  in  the 
patient's  urine. 

Vomiting,  dependent  on  the  anaesthesia,  is  very  common  on  the  day  after  the 
operation,  and  rarely  continues  beyond  this.  On  the  second  or  third  day,  the 
appetite  returns.  The  dressings  are  allowed  to  remain  nine  days  ;  on  the  tenth, 
they  are  removed  under  the  carbolic  acid  spray,  and  the  sutures  are  taken  out. 


288 


Progress  of  the  Medical  Sciences. 


[July 


The  wound  is  found  to  be  united  by  the  first  intention,  without  the  formation  of  a 
drop  of  pus.  The  pedicle  is  always  returned  into  the  abdomen,  as  the  retention 
of  it  outside  the  wound  interferes  with  the  application  of  Lister's  dressing.  Silk 
sutures  certainly  irritate ;  but  Dr.  Schroeder  does  not  know  how  to  do  without 
them,  as  catgut,  he  says,  is  not  to  be  depended  on,  and  he  has  no  faith  in  the 
actual  cautery.  He  used  drainage  of  the  peritoneum  in  only  one  case,  and  con- 
siders that  it  is  never  necessary,  and  sometimes  even  injurious. 

This  communication  of  Dr.  Schroeder  is  a  most  valuable  contribution  to  the 
settlement  of  the  question  as  to  the  applicability  and  utility  of  the  antiseptic 
method  in  ovariotomy.  He  heads  his  paper,  "A  Report  on  Fifty  Listerian 
Ovariotomies  (Lister' sche  Ovariotornien)  ;"  but,  though  he  describes  minutely 
the  antiseptic  precautions  employed,  he  does  not  give  details  as  to  the  manner  in 
which  the  wound  is  dressed — merely  speaking  of  the  "  Occlusivverband."  Any- 
how, his  results  go  to  prove  the  applicability  to  ovariotomy,  if  not  of  Lister's 
method  in  all  its  minutest  details,  at  least  of  a  modification  of  that  method. — 
British  Med.  Journal,  March  23,  1878. 

Ovariotomy  Performed  on  the  Antiseptic  Method,  the  Patient  being  in  a  State  of 

Pyrexia ;  Recovery, 

Dr.  John  AVilliams,  Assistant  Obstetric  Physician  to  University  College 
Hospital,  records  (Lancet,  March  16,  1878)  the  following  case  : — 

Mrs.  D  ,  who  had  had  two  children,  was  seen  by  Mr.  Keele,  of  Highbury, 

in  August,  1876.  She  complained  of  a  severe  pain  in  the  left  inguinal  region; 
it  had  come  on  suddenly,  and  was  greatly  relieved  by  sedatives  and  hot  applica- 
tions. On  examination  the  uterus  was  found  somewhat  enlarged,  and  a  diagno- 
sis of  pregnancy  was  made.  The  abdomen  grew  rapidly  until  March,  1877, 
when  Dr.  Glover  saw  her  in  consultation  with  Mr.  Keele.  Pregnancy  compli- 
cated by  an  ovarian  tumour  was  diagnosed,  and  labour  induced.  A  male  child 
of  six  months  was  soon  born,  and  the  patient  recovered  well  from  the  effects  of 
the  labour.  Before  delivery  the  abdomen  measured  fifty-two  inches  in  circum- 
ference, after  delivery  forty-seven  inches.  The  tumour  grew  rapidly,  and  on 
April  3d  she  was  tapped,  when  thirty  pints  of  thick  grumous  fluid  were  drawn 
off.  She  rapidly  improved,  and  at  the  end  of  May  was  able  to  walk  out.  The 
cyst,  however,  began  to  fill  again,  sickness  set  in  and  became  very  distressing, 
the  temperature  rose,  and  on  August  16th  she  was  again  tapped,  when  fifteen  pints 
of  thick  grumous  fluid  were  drawn  off.  Though  relieved  from  the  effects  of 
pressure,  she  did  not  improve,  for  the  sickness  increased,  the  temperature  con- 
tinued high  and  once  rose  to  104°,  she  had  much  pain,  was  losing  flesh,  and  ex- 
haustion was  increasing  ;  so  on  September  13th  she  was  taken  into  University 
College  Hospital. 

On  admission,  pulse  was  very  feeble,  120  a  minute,  weak  and  irregular;  respi- 
ration 50,  shallow,  with  frequent  sighing;  temperature  102°  F.  Urine  scanty, 
acid,  depositing  a  large  quantity  of  urates  ;  contains  no  albumen  or  sugar.  Ab- 
domen large,  pendulous  ;  lower  part  of  wall  shining  and  oedematous. 

On  September  15th  the  tumour  was  removed  under  carbolic-acid  spray.  All 
instruments,  ligatures,  etc.,  used  were  placed  in  a  solution  (one  in  forty)  of  car- 
bolic acid,  and  the  hands  of  all  helping  in  the  operation  were  washed  in  a  similar 
solution.  An  incision  from  four  to  five  inches  long  was  made  in  the  linea  alba, 
beginning  about  an  inch  below  the  umbilicus.  When  the  peritoneal  cavity  was 
opened  a  considerable  quantity  of  ascitic  fluid  escaped.  The  tumour  was  found 
adherent  to  the  abdominal  wall  in  front  and  on  the  left  side.  The  adhesions 
formed  many  loculi,  which  contained  fluid,  and  most  of  them  were  readily  torn 


1878.]  Midwifery  and  Gynaecology.  289 

through.  The  cyst  was  then  tapped,  but  the  contents  were  too  thick  and  viscid 
to  pass  through  the  tube.  An  incision  was  made  into  it,  the  edges  of  which  were 
kept  outside  the  wound  to  prevent  the  contents  entering  the  cavity  of  the  abdo- 
men. The  solid  parts  of  the  tumour  were  then  broken  up  by  the  hand,  and  the 
mass  drawn  out.  One  adhesion  had  to  be  ligatured.  The  tumour  sprang  from 
the  left  ovary.  The  pedicle  was  transfixed  and  tied  in  two  halves  by  a  strong 
hempen  thread.  The  tumour  was  cut  off,  and  the  pedicle  dropped  into  the 
pelvis.  On  introducing  a  sponge  into  the  peritoneum  it  was  found  that  it  con- 
tained neither  blood  nor  cyst-contents.  The  wound  was  closed  by  four  deep 
carbolized  silk  sutures  with  intermediate  superficial  silver  sutures  j  Lister's  pro- 
tective was  then  applied,  with  a  large  quantity  of  loose  antiseptic  gauze,  and  a 
pad  of  eight  folds  of  gauze  having  a  strip  of  waterproof  between  its  outer  layer. 
The  abdomen  having  been  bandaged,  the  patient  was  placed  in  bed. 

She  was  permitted  to  take  lithia-water,  ice,  barley-water,  milk,  and  a  little 
brandv-and-water  in  case  of  sickness.  She  vomited  two  or  three  times  during 
the  first  three  days.  The  morning  following  the  operation  the  temperature  was 
normal ;  pulse  85  :  respiration  28.  The  wound  was  dressed  first  on  the  fifth  day 
after  operation,  and  it  was  almost  entirely  healed.  It  was  sweet,  and  no  pus  had 
formed.  It  was  dressed  again  on  the  eighth  day,  when  it  was  quite  healed.  The 
patient  recovered  without  a  bad  symptom,  and  was  discharged  on  the  twentieth 
day  after  operation. 

The  tumour  consisted  of  one  large  cyst  containing  a  thick  dirty-brown  gelati- 
nous fluid,  and  a  mass,  forming  about  two-fifths  of  the  whole,  composed  of  a 
number  of  cysts  with  thick  semi-solid  opalescent  substance.  The  fluid  removed, 
together  with  the  ascitic  fluid,  amounted  to  two  gallons. 

A  Case  of  Hydatid  Tumour  of  the  Pelvis,  simulating  Retro-Uterine  Hema- 
tocele. 

Dr.  F.  Yillard  relates  (Annates  de  Gyne'cologie,  Feb.  1878)  a  case  of  retro- 
uterine hydatid  tumour,  which  ended  fatally.  The  patient  was  thirty-two  vears 
old,  and  had  had  three  children,  the  last  three  years  ago.  Menstruation  had 
always  been  normal.  On  one  occasion  the  menses  did  not  appear  till  a  fortnight 
after  time,  and  were  more  scanty  than  usual.  On  the  third  day  of  menstruation, 
she  was  attacked  with  violent  hypogastric  pain  and  vomiting,  and  was  obliged  to 
take  to  her  bed.  The  symptoms  continued  and  increased  during  the  next  five 
weeks,  at  the  end  of  which  Dr.  Yillard  first  saw  the  patient.  She  was  then  much 
exhausted,  pulse  120,  face  expressive  of  suffering,  dorsal  decubitus.  There  was 
frequent  bilious  vomitiug,  and  a  constant,  though  not  considerable,  discharge  of 
dark  blood  continued.  For  two  or  three  days  there  had  been  a  general  icteric 
tint  of  skin. 

On  examining  the  abdomen,  a  deep  swelling  was  felt  toward  the  risdit  side, 
reaching  nearly  as  high  as  the  liver,  and  passing  over  the  median  line  toward  the 
left.  Another  swelling,  the  fundus  uteri,  was  felt  above  the  pubes.  Per  vaginam. 
a  rounded,  somewhat  elastic  swelling  was  felt,  occupying  the  whole  posterior  cul- 
de-sac,  and  continuous  with  the  abdominal  tumour.  The  cervix  was  much  dis- 
placed forwards  and  upwards,  and  the  os  was  somewhat  patulous,  admitting  the 
tip  of  the  finger.    The  diagnosis  made  was  that  of  retro-uterine  haematocele. 

On  January  8  some  improvement  had  taken  place,  but  the  hemorrhage  con- 
tinued, although  not  in  great  amount.  On  the  12th  prostration  had  increased, 
the  pulse  was  thready,  and  the  icteric  tint  had  increased.  The  next  mornino-  it 
was  reported  that  the  patient  had  been  delivered  of  serpent's  eggs,  and  it  was 
found  that  she  had  passed  about  two  litres  of  blood  mingled  with  innumerable 
Xo.  CLI  July  1878.  19 


290 


Progress  of  the  Medical  Sciences. 


[July 


hydatid  vesicles.  On  vaginal  examination,  an  aperture  was  found  through  the 
posterior  cul-de-sac  into  the  pelvic  cavity,  and  the  tumour  had  collapsed.  The 
patient  died  a  few  hours  after,  but  no  autopsy  was  permitted. 

The  author  collects  for  comparison  twelve  recorded  cases  of  hydatid  tumour  of 
the  pelvis.  In  two  of  these  the  seat  of  disease  was  the  ovary,  which  had  become 
fixed  in  the  pelvis  behind  the  uterus,  in  three  the  recto-vaginal  septum,  in  the 
remaining  seven  the  sub-peritoneal  cellular  tissue.  The  very  grave  nature  of  the 
disease  in  such  a  situation  was  shown  by  the  fact  that  eight  of  the  twelve  cases 
ended  fatally,  seven  of  them  without  any  operative  interference.  In  one  recoverv 
took  place  without  interference,  in  three  after  incision  of  the  cyst.  In  no  siugle 
case  was  the  hydatid  thrill  observed,  probably  on  account  of  the  deep  situation  of 
the  tumour,  but  it  is  also  probable  that  frequently,  as  in  the  author's  own  case,  it 
had  not  been  sought  for.  In  conclusion,  the  history  of  these  cases  shows  that 
the  symptoms  and  physical  signs  were  simply  those  which  might  be  produced  by 
any  tumour  in  the  same  situation,  and  that  the  only  possible  means  of  certain 
diagnosis  is  the  evacuation,  natural  or  artificial,  of  the  contained  fluid.  The  au- 
thor recommends  free  incisions  of  the  cyst,  followed  by  antiseptic  injections, 
remarking  that,  in  his  own  case,  a  simple  puncture  would  not  have  evacuated 
the  numerous  secondary  cysts. — Obstetrical  Journal  of  Great  Britain,  May, 
1878. 


MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 

Fatal  Pistol-Shot  without  Perforation  of  the  Skin. 

Dr.  Hofmaxx  (Lehrbuch  tier  Gerichtlich.  Medicin,  2  Band,  Wien,  1878) 
relates  the  following  remarkable  case.  A  man,  aged  40,  fired  a  pistol-shot  at 
himself  in  the  region  of  the  left  breast.  A  skin-burn  resulted  of  the  size  of  the 
palm  of  the  hand,  but  no  rupture  of  continuity  of  the  external  skin.  Beneath 
this,  there  was  an  effusion  of  blood ;  the  costal  cartilage  was  broken.  In  the 
pericardium  lay  a  pound  and  a  half  of  blood ;  and  at  the  apex  of  the  heart,  on 
each  side  of  the  longitudinal  sulcus,  was  a  rent  of  the  muscular  fibres,  extending 
into  the  cavities  of  the  ventricles. — British  Med.  Journal,  March  16,  1878. 

Sulphuric  Acid  as  an  Antidote  to  Carbolic  Acid. 
Dr.  Senftlebex  (Deutsche  Militairarztl  Zeitschrift,  Heft  1,  1878),  recom- 
mends sulphuric  acid  as  a  remedy  for  the  toxic  symptoms  produced  by  carbolic  acid. 
The  poisoning  is  produced  by  the  presence  of  phenol  in  the  blood ;  and  he  says 
that  the  sulphuric  acid,  combining  with  this,  produces  sulphocarbolic  acid,  which 
is  innocuous.  He  has  treated  several  cases  successfully  on  this  principle.  The 
mixture  which  he  uses  is :  Dilute  sulphuric  acid,  one  part ;  gum  water,  two  hun- 
dred parts ;  syrup,  thirty  parts ;  one  tablespoonful  to  be  taken  every  hour. — Lon- 
don Med.  Record,  May  15,  1878. 


1878.] 


291 


AMERICAN  INTELLIGENCE. 

ORIGINAL  COMMUNICATIONS. 

Acute  Inversion  of  the  Uterus.  By  Samuel  Hall,  M.D.,  of  Reeds- 
burgh,  Sauk  County,  Wisconsin. 

On  July  25,  1877,  I  was  called  in  great  haste  to  see  a  German  woman, 
a't.  about  20  years,  who  had  just  been  delivered  of  her  first  child.  The 
midwife  who  was  in  attendance  said  that  the  patient  had  a  very  rapid  de- 
livery ;  that  soon  after  something  came  away,  she  did  not  know  what  it 
was,  but  that  she  was  flowing  to  death.  I  found  the  patient  lying  on  her 
back,  pale  and  anxious,  lips  colourless,  pulse  small,  and  very  frequent, 
seemingly  in  "  articulo  mortis."  Examination  revealed  a  long  tumour, 
somewhat  rounded  at  the  base,  protruding  through  the  vulva,  between 
the  thighs ;  lying  beside  it  and  almost  detached,  was  the  placenta ;  blood 
was  fast  oozing  from  the  surface  of  the  tumour,  and  slipping  down  in  suc- 
cessive clots  from  it ;  the  tumour  was  diagnosed  as  an  inverted  uterus  ;  it 
was  firmly  contracted,  and  hard. 

As  there  was  no  time  for  delay,  I  at  once  proceeded  to  detach  the  re- 
maining portion  of  the  placenta,  and  remove  it,  which  was  very  easily 
done ;  then  while  my  left  hand  firmly  grasped  and  held  the  tumour  from 
receding  upward  into  the  vagina  (as  it  was  very  much  inclined  to  do 
when  pressure  upward  was  made)  with  the  thumb  of  my  right,  I  made 
effort  to  indent  the  wall  of  the  inverted  fundus  ;  after  patient  and  con- 
tinued pressure,  I  at  last  succeeded  in  making  a  slight  impression.  Be- 
coming quite  fatigued,  and  my  thumb  almost  paralyzed,  from  the  long  con- 
tinued effort,  as  applied  by  it,  I  found  it  necessary  to  suspend  pressure,  in 
order  to  bring  the  ends  of  my  fingers  (brought  together  in  the  shape  of  a 
cone)  to  bear  on  the  indentation  made. 

I  had  expected  when  pressure  was  removed  to  make  the  change,  that 
the  dent  would  return,  and  my  labour  all  be  lost,  but  to  my  great  satisfac- 
tion there  was  no  such  result. 

The  reversion  of  the  organ  was  now  more  rapid,  so  that  continuing  the 
pressure  with  my  right  hand,  I  very  soon  released  my  grasp  with  the  left, 
and  permitted  the  organ  to  recede  upward  through  the  vulva,  the  vaginal 
walls  were  put  on  the  stretch,  and  the  whole  uterine  body  passed  readily 
through  the  mouth  and  cervical  canal,  which  were  now  well  dilated,  and 
the  uterus  was  restored  to  its  normal  position.  My  hand  was  passed  over 
the  entire  internal  surface  to  satisfy  myself  that  all  parts  of  the  wall  were 
completely  returned,  retaining  it  there  until  firm  contraction  came  on, 
when  it  was  slowly  withdrawn. 

Saw  patient  comfortably  placed  in  bed,  advised  her  to  have  rest  and 
quiet.  No  untoward  circumstance  prevented  a  good  and  speedy  get- 
ting-up. 


292 


American  Intelligence. 


[July 


DOMESTIC  SUMMARY. 

Laparo-Elytrotomy :  a  Substitute  for  the  Ccesarean  Section. 

At  a  late  meeting  of  the  New  York  Academy  of  Medicine,  Dr.  T.  GaillArd 
Thomas  read  a  very  important  paper  {Am.  Journal  of  Obstetrics,  April,  1878) 
descriptive  of  this  operation  and  its  results. 

This  operation  consists  in  cutting  through  the  abdominal  walls  by  an  incision 
above  Poupart's  ligament,  extending  from  the  spine  of  the  pubes  to  the  anterior 
superior  spinous  process  of  the  ilium,  avoiding  the  peritoneum  by  lifting  it  up  with 
the  fingers  and  then  cutting  through  the  vagina,  which  is  pushed  upwards  into 
the  iliac  opening  by  a  sound  or  the  finger  of  an  assistant,  and  delivering  through 
the  os  uteri.  This  operation  was  conceived  by  Dr.  Thomas,  and  he  did  not  dis- 
cover until  some  time  afterward  that  it  had  been  proposed  in  180G  by  Jorg,  and 
modified  and  executed  with  fatal  result  in  one  case  by  Ilitgen.1 

The  operation  of  laparo-elvtrotomy  has  now  been  performed  twice  by  Dr. 
Thomas,  and  three  times  by  Dr.  Skene,  with  safety  to  the  mothers  in  three  of 
the  cases,  and  with  the  delivery  of  living  children  in  four.  To  this  statement 
should  be  added  the  facts  that  in  one  case  the  mother  was  in  articulo  mortis,  and 
the  operation  was  performed  in  the  interest  of  the  child  alone,  who  was  bom 
alive  and  uninjured  ;  in  another,  it  was  undertaken  solely  f  or  the  relief  of  the 
mother,  who  was  almost  moribund,  the  child  being  already  dead.  In  three  of 
the  cases  the  bladder  was  injured,  so  that  a  fistulous  orifice  resulted,  which,  in  two 
of  them,  healed  spontaneously. 

Dr.  Thomas  considers  whether  laparo-elvtrotomy  avoids  the  dangers  attending 
upon  laparo-hysterotomy,  and  in  what  manner  such  avoidance  is  effected.  The 
chief  dangers,  of  the  latter  procedure  are:  1st.  Peritonitis;  2d.  Metritis;  3d. 
Hemorrhage;  4th.  Shock  ;  5th.  Incarceration  of  intestines  in  uterus  ;  6th.  Sep- 
ticaemia.  The  operation  of  laparo-elvtrotomy  avoids  entirely  the  first,  second, 
and  fifth  of  these  dangers,  and  in  great  degree  diminishes  the  probability  of  tin- 
fourth  and  sixth.  It  may  be  followed  by  the  third  (hemorrhage),  and  in  place 
of  peritonitis  may  create  cellulitis.  As  neither  peritoneum  nor  uterus  are  cut,  the 
great  risks  of  inflammation  of  these  parts,  together  with  that  of  hernia  into  the 
uterus,  are  avoided.  The  peritoneal  cavity  being  unopened,  there  is  little  danger 
of  that  sudden  nervous  prostration  which  we  style  shock  ;  and  as  the  wound  ad- 
mits of  being  flooded  constantly  with  carbolized  water,  the  probability  of  the 
occurrence  of  septicaemia  is  very  much  lessened. 

The  great  danger  to  be  apprehended  is  unquestionably  hemorrhage.  In  none 
of  the  five  cases  reported  did  it  occur,  but  the  future  may  belie  the  past  in 
this  regard.  There  is  a  congerie  of  large,  tortuous  arteries  around  the  vagina 
which  must  be  severed;  but  by  means  of  ligatures,  the  actual  cautery,  or  such 
styptics  as  the  persulphate  of  iron,  hemorrhage  could  probably  be  controlled,  even 
if  it  did  occur. 

Dr.  Thomas  concludes  his  very  valuable  paper  by  giving  the  following  advice 
concerning  the  details  of  the  consecutive  steps  of  this  operation  :  — 

First.  The  operator  should  be  provided  with  a  pocket-case  of  instruments, 
ether,  Barnes's  dilators,  and  Paquelin's  thermo-cautery,  or,  in  place  of  it,  ordinary 
cautery- irons. 

Second.  The  patient  having  been  etherized,  she  should  be  placed  upon  a  firm 
table,  and  the  os  fully  dilated  by  Barnes's  dilators. 

Third.  The  abdominal  wound  should  be  made;  the  peritoneum  lifted;  the 


1  Kalian,  Op.  Geburtshulfle.  vol.  ii.  p.  715. 


1878.] 


Domestic  Summary. 


293 


vagina  opened;  and  the  child  delivered  by  version,  if  the  head  or  arm  present ; 
by  extraction,  if  the  breech  do  so. 

Fourth.  The  placenta  having  been  delivered,  and  the  uterus  caused  to  contract 
firmly,  the  iliac  fossa  should  be  cleansed  by  a  stream  of  warm  water,  introduced 
through  the  abdominal  wound,  and  escaping  through  the  vagina ;  and  if  hemor- 
rhage exist,  ligatures  should  be  applied,  if  possible  through  the  abdominal  wound, 
to  the  bleeding  vessels.  Should  this  prove  impossible,  the  vagina  should  be  dis- 
tended by  a  large  metallic  speculum,  and  the  lips  of  the  abdominal  wound  being 
widely  separated,  the  bleeding  points  touched  by  the  actual  cautery  carried  down 
from  above.  Should  this  fail,  the  uterus  should  be  made  to  contract  firmly  by 
ergot,  and  both  vagina  and  iliac  fossa  be  thoroughly  tamponed  with  cotton  soaked 
in  water  and  squeezed,  but  free  from  any  styptic.  Then  a  broad  band  of  adhe- 
sive plaster,  and  a  compress  should  be  applied  over  the  lower  portion  of  the 
abdomen. 

Fifth.  Should  no  undue  hemorrhage  occur,  the  abdominal  wound  should  be 
closed  by  interrupted  silver  sutures  ;  the  vagina  should  be  syringed  out  every  five 
hours  with  warm  carbolized  water,  the  nozzle  of  the  syringe  being  carried  through 
the  vaginal  opening,  ami  the  fluid  forced  out  through  that  in  the  abdomen.  The 
patient  should  be  kept  perfectly  quiet,  nourished  by  milk  and  animal  broths,  and 
kept  free  from  pain  by  opium. 

Intra-Venous  Injection  of  Milk  as  a  Substitute  for  Transfusion  of  Blood. 

Dr.  T.  Gaillakd  Thomas  recently  read  a  valuable  paper  before  the  New 
York  Academy  of  Medicine  (Med.  Record,  April  27,  1878)  upon  the  above  sub- 
ject, in  which  reference  was  first  made  to  the  origin,  the  history,  and  the  present 
status  of  the  operation  of  transfusion  of  blood. 

To  the  question.  --What  is  the  real  status  of  this  resource  in  medicine?"  Dr. 
Thomas  gave  the  following  answer :  "Transfusion  of  blood  into  the  human  system 
is  an  operation  the  plausibility  and  theoretical  advantages  of  which  all  admit,  but 
practically  the  results  of  the  operation  amount  to  but  very  little  indeed." 

The  insecure  position  which  the  operation  occupied  practically,  was  due  largely 
to  its  inherent  difficulties  and  dangers,  nearly  all  of  which  arose  from  the  tendency 
of  the  blood  to  coagulate.  To  overcome  those  difficulties  and  dangers  various 
methods  of  preparing  the  blood  for  intra- venous  injection  had  been  suggested,  and 
other  fluids  had  also  been  offered  as  a  substitute.  The  object  of  the  paper  was  to 
prove  that  in  the  milk  of  the  cow  we  had  a  fluid  which  met  all  the  theoretical  and 
practical  requirements  of  a  safe  intra- venous  injection. 

Dr.  Thomas  then  related  the  cases  in  which  he  had  resorted  to  intra- venous 
injections  of  milk  as  a  substitute  for  transfusion  of  blood. 

The  first  case  was  operated  upon  by  Dr.  Thomas  for  the  removal  of  a  large 
abdominal  tumour  in  October,  1875.  The  case,  in  all  its  details,  had  "already 
been  published.1  Because  of  the  severe  loss  of  blood  subsequent  to  the  operation, 
and  the  general  condition  of  the  patient,  it  was  resolved  to  resort  to  intra-venous 
injections  of  some  restorative  fluid,  and  Dr.  Thomas  decided  to  employ  for  that 
purpose  perfectly  pure  fresh  milk.  The  suggestion  of  using  intra-venous  injec- 
tions of  milk  was  made  by  Dr.  E.  M.  Hodder,  of  Toronto,  Canada,  who,  twenty- 
eight  years  ago,  employed  it  in  the  treatment  of  collapse  in  cases  of  Asiatic 
cholera.  The  suggestion  was  revived  by  Dr.  J.  W.  Howe,  of  New  York,  who, 
about  one  year  previous  to  Dr.  Thomas's  first  operation,  had  injected  ^vj  of 
goat's  milk  into  the  cephalic  vein  of  a  patient  suffering  from  phthisis. 

Accordingly  a  healthy  cow  was  driven  into  the  yard,  and  ^viiiss  of  milk,  drawn 


1  Amer.  Journ.  of  Med.  Sci.,  Jan.  1876,  p.  61. 


294 


American  Intellig  enc  e. 


from  her  udder  into  a  porcelain  dish  surrounded  with  warm  water,  was  permitted 
to  flow  slowly  into  the  median  basilic  vein  of  the  patient  from  a  glass  funnel  to 
which  was  attached  a  rubber  tube  and  a  suitable  nozzle  to  be  introduced  into  the 
opening  in  the  bloodvessel.  A  rigor  followed  the  operation;  the  temperature 
rose  to  104°  F. ;  but  those  symptoms  soon  passed  away.  On  the  twenty-first 
day  the  lady  was  able  to  walk  down  stairs,  and  recovery  was  soon  complete. 

Soon  after,  Dr.  J.  W.  Howe  made  some  experiments  upon  dogs.  Into  the 
veins  of  five  animals  he  injected  milk,  and  all  died  promptly.  Dr.  Dupuy  repeated 
Dr.  Howe's  experiments,  and  found  that  injections  of  milk  which  had  been 
removed  from  the  cow  for  a  very  short  time  uniformly  proved  fatal,  while  the  in- 
jection of  perfectly  fresh  milk  was  entirely  innocuous.  These  experiments  re- 
vealed the  secret  of  failure  in  Dr.  Howe's  experiments.  The  milk  which  he  had 
employed  had  been  drawn  from  the  cow  an  hour  or  two  previous  to  the  time  it 
was  used,  and  had  been  transferred  to  the  city  in  a  railroad  car.  It  had  probably 
undergone  chemical  changes  before  it  was  used  in  the  experiment. 

The  second  case  reported  by  Dr.  Thomas  was  operated  upon  for  ovariotomy. 
Feb.  3,  1878.  Extensive  adhesions  were  encountered.  Peritonitis  and  abscess 
followed,  and  the  condition  of  the  patient  became  so  grave  that,  on  the  twentieth 
day  after  the  operation  it  was  determined  to  resort  to  intra-venous  injections  of 
milk.  A  cow  was  secured,  and  the  milk,  drawn  into  a  pitcher  covered  with  car- 
bolized  gauze,  was,  in  less  than  one  minute  from  the  time  it  was  taken,  flowing 
slowly  into  the  vein  of  the  patient.  On  the  first  of  March  a  second  injection  was 
made,  and  3xv  of  milk,  taken  in  the  manner  referred  to,  was  allowed  to  flow 
slowly  into  the  vein.  The  injections  were  repeated  March  2d,  4th,  and  5th,  and 
twelve,  six,  and  eight  ounces  of  milk  respectively  used.  The  case  terminated 
fatally.  The  result,  however,  could  not  be  used  as  an  argument  against  the  ope- 
ration, because,  when  the  first  injection  was  made,  the  patient  was  fairly  mori- 
bund. At  each  subsequent  operation  it  was  the  unanimous  opinion  of  all  who  saw 
the  patient  that  death  was  inevitable  within  a  very  brief  space  of  time.  It  was 
thought  that  the  patient's  life  was  prolonged  at  least  six  days  by  the  five  intra- 
venous injections  of  milk.  At  the  autopsy  there  was  found  localized  gangrene  of 
the  intestines,  which  proved  that  the  case  must  have  inevitably  terminated  fatally. 

The  third  case  reported  simply  proved  that  milk  injected  into  the  circulation 
was  innocuous. 

There  are  twelve  cases  upon  record  in  which  intra-venous  injections  of  milk 
had  been  employed  in  the  human  subject:  three  by  Hodder,  two  by  Howe,  and 
seven  by  Thomas. 

Dr.  A.  Jacobi  remarked  that  there  was  one  point  upon  which  Dr.  Thomas  had 
not  dwelt,  and  to  which  he  would  make  allusion.  Dr.  Thomas  had  referred  in 
general  terms  to  the  poisonous  character  of  milk  which  was  an  hour  or  two  old. 
Naturally,  we  would  not  expect  that  any  chemical  change  existed  in  cow's  milk 
immediately  after  its  removal.  But  there  were  a  certain  number  of  cows  in  which 
the  milk  had  an  acid  reaction  even  when  in  the  udder.  A  large  number  of  speci- 
mens of  milk  were  neutral,  and  turned  acid  very  quickly  after  removal.  But 
whether  neutral,  or  acid,  or  alkaline,  depended  to  a  great  extent  upon  the  food 
which  the  animal  had  taken. 

It  was  necessary  that  cows  should  feed  in  pasture  in  order  that  the  milk  should 
be  naturally  alkaline.  Milk  to  be  introduced  into  the  blood  must  be  alkaline,  for 
the  blood  did  not  at  all  tolerate  the  presence  of  acids.  It  was  that  fact  probably 
that  gave  explanation  to  the  ill  effects  produced  in  Dr.  Howe's  experiment,  and 
the  absence  of  ill  effects  in  Dr.  Dupuy' s  experiments.  The  question  then  sug- 
gested itself,  would  it  not  be  well  in  every  case,  before  the  milk  was  used,  to  test 
it  with  litmus-paper,  and  if  it  be  acid,  to  make  it  alkaline  by  the  addition  of  car- 


1878.] 


Domestic  Summary. 


295 


bonate  of  soda?  Cow's  milk,  when  introduced  into  the  blood,  should  be  a  little 
more  alkaline  than  it  was  naturally.  Again,  it  would,  perhaps,  be  well  to  warn 
operators  against  injecting  too  large  quantity  at  a  single  operation. 

Dr.  Thomas  remarked  that  the  point  last  referred  to  by  Dr.  Jaeobi  had  been 
illustrated  in  the  case  in  which  five  injections  were  given.  From  six  to  eight 
ounces  was  probably  about  a  reasonable  quantity ;  eight  was  probably  the  maxi- 
mum, and  five  the  minimum  quantity  to  be  used  at  a  single  operation. 

The  conclusions  reached  by  Dr.  Thomas  are  embraced  in  the  following  propo- 
sitions :  — 

1.  The  injection  of  milk  into  the  circulation  in  place  of  blood  is  a  perfectly 
feasible,  safe,  and  legitimate  procedure,  which  enables  us  to  avoid  most  of  the 
difficulties  and  dangers  of  the  latter  operation. 

2.  In  this  procedure,  none  but  milk  removed  from  a  healthy  cow  within  a  few 
minutes  of  the  injection  should  be  employed.  Decomposed  milk  is  poisonous, 
and  should  no  more  lie  used  than  decomposed  blood. 

3.  A  glass  funnel,  with  a  rubber  tube  attached  to  it,  ending  in  a  very  small 
canula,  is  better,  safer,  and  more  attainable  than  a  more  elaborate  apparatus, 
which  is  apt,  in  spite  of  all  precautions,  to  admit  air  to  the  circulation. 

4.  The  intra-venous  injection  of  milk  is  infinitely  easier  than  the  transfusion  of 
blood.  Any  one  at  all  familiar  with  surgical  operations  may  practise  it  without 
fear  of  great  difficulty  or  of  failure. 

5.  The  injection  of  milk,  like  that  of  blood,  is  commonly  followed  by  a  chill, 
and  rapid  and  marked  rise  of  temperature;  then  all  subsides,  and  great  improve- 
ment shows  itself  in  the  patient's  condition. 

6.  I  would  not  limit  lacteal  injections  to  cases  prostrated  by  hemorrhage,  but 
would  employ  it  in  disorders  which  greatly  depreciate  the  blood,  as  Asiatic  cholera, 
pernicious  anaemia,  typhoid  fever,  etc.,  and  as  a  substitute  for  diseased  blood  in 
certain  affections  which  immediately  call  for  the  free  use  of  the  lancet,  as  puer- 
peral convulsions,  etc. 

7.  Not  more  than  eight  ounces  of  milk  should  be  injected  at  one  operation. 

8.  In  conclusion,  I  would  suggest  that,  if  milk  answers,  not  as  good,  but  nearly 
as  good,  a  purpose  as  blood  under  these  circumstances,  its  use  will  create  a  new 
era  in  this  most  interesting  department  of  medicine.  That  it  will  answer  such  a 
purpose,  I  am  convinced  from  lengthy  consideration  and  some  experience  of  the 
matter;  and  I  would  be  false  to  my  own  convictions  if  I  did  not  predict  for 
"Intra-venous  Lacteal  Injection"  a  brilliant  and  useful  future. 

A  New  Metliod  of  Denuding  Tissues. 

Dr.  Albert  H.  Smith,  of  Phila.,  at  the  recent  meeting  of  the  American 
Medical  Association  at  Buffalo,  reported  some  experiments  lately  made  with  the 
burr  of  the  dental  engine,  rotated  with  great  velocity  by  Bonwill's  flexible  shaft, 
by  which  he  has  successfully  denuded  tissues  in  the  restorative  operations  upon  the 
female  pelvic  organs.  In  the  perineal  operation  and  in  Emmett's  operations  for 
lacerated  cervix,  he  has  had  the  most  satisfactory  results.  He  claims  for  the 
metliod,  great  economy  of  tissue  in  the  removal  of  a  thin  film  ;  perfect  control  of 
action  in  deeper  cutting  ;  the  production  of  a  surface  as  fresh  as  if  cut  by  a  knife, 
yet  bleeding  less  in  the  superficial  denudation  because  it  is  less  deep  than  must 
necessarily  be  made  with  a  knife  cleanly ;  also  of  a  surface,  smooth  and  uniform  in 
character,  especially  adapted  for  facilitating  a  close  and  accurate  adjustment,  as 
so  urgently  necessary  in  the  plastic  operations  upon  the  cervix. 

The  effect  may  be  had  either  from  the  steel  burr,  which  Dr.  Smith  had  made 
for  the  special  purpose,  or  from  coarse  corundum  wheels. 


296 


AmEBI  C  A  N  I  X  T  ELLIG  E  N  <  E  . 


[July 


Partial  Excision  of  Spleen. 

Dr.  A.  A.  Faris  reports  (Am.  Practitioner,  May,  1878)  the  case  of  Davis 
B.,  aged  36,  of  strong  frame,  but  somewhat  debilitated  by  reason  of  malarial 
fevers  and  their  sequelae,  having  also  a  much  enlarged  spleen.  Whilst  en^a^ed 
in  a  fray  that  occurred  on  the  first  of  February,  1874,  he  was  cut  with  a  knife, 
the  blade  of  which  was  four  inches  long  and  three-fourths  of  an  inch  broad.  Dr. 
Faris  saw  him  soon  after  the  injury,  and  found  him  suffering  with  two  penetrating 
wounds  of  the  left  breast — one  entering  the  lung  through  the  third  intercostal 
space  just  above  the  nipple,  and  the  other  through  the  second  space  near 
the  sternum;  also  two  wounds  of  the  left  arm — one  through  the  upper  third 
of  the  upper  arm,  the  other  through  the  ulno-radial  space  in  the  middle  of  the 
lower  arm.  There  was  also  an  incised  wound,  commencing  one  inch  above  the 
ant.  sup.  spinous  process  of  the  left  ilium,  extending  upward  and  backward  three 
inches,  through  which  protruded  a  portion  of  the  spleen,  with  a  piece  three 
inches  long  and  one  inch  wide  (in  the  centre)  cut  from  its  lower  border,  and 
hanging  by  a  slender  pedicle.  Hemorrhage  had  been  arrested  by  forced  flexion 
of  the  thigh,  not  until  much  blood  had  been  lost,  however. 

Dr.  Faris  cut  off  the  partially  detached  portion  of  the  spleen,  pressed  the 
edges  of  the  wound  firmly  together,  and  carefully  pushed  the  spleen  inward  until 
the  cut  surface  was  level  with  the  integument ;  then,  with  a  large  curved  needle, 
sewed  the  spleen  and  walls  of  the  abdomen  together,  compressing  them  tightly 
Avith  quill  sutures,  afterwards  approximating  as  near  as  he  could  the  edges  of  the 
integument  over  the  cut  surface  of  the  spleen  with  a  small  silk  suture. 

The  wounds  healed  kindly,  and  the  patient  is  now  enjoying  good  health. 

Subperiosteal  Excision  of  the  Entire  Scapula  and  Head  of  the  (right) 
Humerus;  Recovery. 
Dr.  Charles  B.  Brighah,  of  San  Francisco,  reports  (Boston  Medical  and 
Surgical  Journal,  April  11,  1878)  a  case  of  this.  The  operation  was  performed 
on  account  of  necrosis.  The  scapula  was  excised  by  a  single  incision  along  the 
spine.  The  bone  came  away  entire.  The  patient  can  now  (one  month  after 
the  operation)  put  his  right  hand  to  his  left  shoulder  unassisted ;  he  can  move  his 
arm  backwards  and  forwards  an  inch  in  each  direction,  and  has  full  use  of  the 
right  hand  in  writing,  eating,  and  in  all  the  ordinary  movements. 

Hare-lip  and  Cleft  Palate  in  the  Negro. 

In  reply  to  the  inquiry  whether  hare-lip  occurs  in  the  negro,  and  if  it  occurs 
whether  it  is  not  rarer  in  him  than  in  the  white  race,  Dr.  Middletox  Michel, 
Prof,  of  Physiology  and  Histology  in  the  Med.  College  of  the  State  of  South 
Carolina,  contributes  (Charleston  Med.  Journ.  and  Review,  July,  1876)  an  in- 
teresting  paper,  in  which  he  has  collected  the  notes  of  thirty-two  cases  of  con- 
genital hare-lip  and  cleft  palate  in  the  full-blooded  negro,  and  he  does  not  believe 
that  the  defect  is  rare  among  them.  He  also  shows  that  hare-lip  occurs  in  the 
lower  animals,  and  that  this  malformation  does  not  depend  upon  mal-nutrition. 
but  is  the  result  of  an  inexplicable  deviation  of  cell-genesi;. 

Smallpox  in  the  Pregnant  Woman  and  in  the  Foetus. 
Dr.  W.  M.  Welch,  Physician  to  the  Philadelphia  Smallpox  Hospital,  con- 
tributes to  the  Medical  Times  (May  25.  1878)  an  extremely  interesting  paper  on 
this  subject,  based  on  a  study  of  forty-six  cases.    He  sums  up  his  conclusions  as 
follows :  — 


1878.] 


Domestic  Summary. 


297 


1 .  Smallpox  in  the  female  disturbs  with  striking  frequency  the  functions  of  the 
womb,  giving  rise  in  the  non-pregnant  woman  to  premature  appearance  of  the 
menses,  and,  in  the  pregnant  woman,  frequently  exciting  abortion. 

2.  Abortion  is  a  very  serious  complication  of  smallpox.  The  earlier  in  the 
course  of  the  disease  it  occurs,  the  more  serious  is  the  complication. 

3.  The  foetus  does  not  generally  undergo  smallpox  in  utero,  although  occasion- 
ally such  may  be  the  case. 

4.  When  a  pregnant  woman  undergoes  smallpox  without  miscarriage  occurring, 
the  susceptibility  to  the  disease  in  the  infant  is  not  destroyed. 

Spaying  on  account  of  Severe  Dysmenorrhea. 

Dr.  W.  C.  Frew,  of  Coshocton,  Ohio,  reports  (Ohio  Medical  Recorder, 
May,  1878)  the  case  of  M.  E.,  aged  24.  single,  who  had  suffered  from  violent 
dysmenorrhcea  ever  since  menstruation  had  been  established.  The  pain  was 
intense,  and  during  the  first  day  morphia  completely  failed  to  relieve  it.  It  con- 
fined her  to  bed,  and  lasted  for  five  or  six  days.  On  the  first  day,  her  pulse  and 
temperature  would  rise,  the  former  frequently  to  1 20  ;  the  latter  to  102-103°, 
and  her  abdomen  would  become  tympanitic  and  excessively  tender.  There  was 
complete  anorexia,  and  sometimes  nausea  and  vomiting ;  this  condition  would 
last  for  a  week  or  ten  days,  and  then  gradually  disappear.  These  attacks  were 
sometimes  accompanied  by  complete  suppression  of  urine;  I  have  known  her  to 
go  two  or  three  days,  and,  on  one  occasion,  four  days  without  passing  a  drop  of 
urine,  and  none  could  be  found  with  the  catheter.  She  was  subject  to  all  forms 
of  hysterical  manifestations — convulsions,  paralysis,  anaesthesia,  hyperesthesia, 
and  mania.  She  had  had,  also,  several  attacks  of  chorea,  each  of  which  lasted 
for  several  months,  and  was  greatly  aggravated  at  the  menstrual  epochs ;  gene- 
rally, after  the  period  had  passed,  she  would  gradually  improve  in  health  until  a 
fresh  attack  would  prostrate  her  again.  She  was  a  chronic  invalid,  one-third  of 
her  time  confined  to  her  bed,  one- third  to  her  room,  and  almost  the  whole  of  the 
last  third  to  the  house. 

There  was  no  obstruction  to  the  free  escape  of  the  catamenial  fluid.  No  se- 
rious displacement,  and  no  organic  disease  of  the  womb  could  be  detected. 
There  was  severe  vaginismus  and  tenderness  in  the  pelvic  region,  even  when  she 
was  enjoying  her  best  health,  so  that  for  a  thorough  examination  anaesthesia  was 
necessary.  Her  condition  seemed  to  progressively  grow  worse.  When  Dr.  Frew 
suggested  extirpation  of  the  ovaries  as  a  last  resort,  she  immediately  insisted 
upon  the  operation,  although  informed  of  its  dangers.  Life  to  her  as  it  was,  she 
said,  was  worse  than  worthless. 

After  consultation  with  Dr.  Skene,  of  Brooklyn,  and  with  the  assistance  of 
Drs.  Johnson  and  Love,  Dr.  Frew,  on  11th  March,  1877,  removed  both  ovaries 
through  an  abdominal  incision.  The  pedicles  were  ligated,  and  the  ligatures  cut 
short  and  dropped  into  the  abdomen.  The  only  unlooked-for  symptom  during 
the  first  week  was  a  sanguineous  discharge  from  the  vagina,  which  began  two 
days  after  the  ojieration  and  continued  at  intervals  for  three  weeks,  occasionally 
quite  profuse,  but  most  of  the  time  very  scanty.  Her  complete  recovery  was 
only  interrupted  by  a  slight  attack  of  pelvic  cellulitis  in  the  second  week. 

Six  months  later  the  patient  was  very  much  improved  in  appearance.  She  men- 
struated on  the  11th  of  September,  just  six  months  from  the  date  of  the  opera- 
tion, and  again  on  October  4th.  These  hemorrhages  were  accompanied  by  pain, 
but  not  nearly  so  severe  as  formerly.  The  first  was  light  and  of  short  duration  ; 
the  second  was  profuse. 

Since  that  time,  she  writes  me,  she  has  menstruated  profusely  about  once  in 


208 


American  Intelligence. 


[July  1878. 


two  months,  and  has  suffered  considerably  with  it.  Her  mother  writes  that  she 
has  had  no  hysteria  or  other  nervous  symptoms  since  the  operation. 

The  ovaries  were  sent  to  Prof.  J.  C.  Dalton,  who  pronounced  them  healthy. 

Tracheotomy  in  Diphtheritic  Croup. 

Concerning  the  value  of  tracheotomy  in  diphtheria  additional  information  is 
still  desired.    Dr.  R.  G.  Bogue  contributes  (Chicago  Med.  Journ.,  Feb.  1878) 
a  report  of  fifteen  cases  in  which  he  operated,  and  of  which  six  were  successful. 
Dr.  Bogue's  experience  in  these  cases  has  led  him  to  the  following  conclusions :  — 

1st.  That  the  so-called  membranous  croup  and  diphtheritic  croup  are  the  same 
disease,  differing  only  in  location,  but  requiring  the  same  treatment. 

2d.  That  tracheotomy  should  be  resorted  to  in  all  cases  where  death  is  threat- 
ened by  suffocation  from  obstruction  in  the  larynx,  and  as  soon  as  the  breathing 
has  become  insufficient  to  sustain  the  vital  powers,  and  should  be  resorted  to  during 
the  so-called  second  stage  of  the  disease. 

3d.  It  is  best,  in  the  majority  of  cases,  to  use  an  anesthetic. 

4th.  The  trachea  should  be  reached  by  careful  dissection,  and  only  opened  after 
cessation  of  hemorrhage. 

5th.  A  tube  should  be  used. 

6th.  The  temperature  of  the  room  should  be  not  less  than  75°,  and  free  from 
currents  of  air.  The  air  should  be  kept  thoroughly  saturated  with  steam.  The 
vapour  may  be  medicated.  Dr.  Bogue  has  used  mostly  a  solution  of  glycerine 
(1-G),  to  which  a  little  chlorate  of  potassa  or  carbolic  acid  may  be  added. 

7th.  The  patient  must  be  sustained  by  food.  There  may  be,  during  the  first 
night  after  the  removal  of  the  tube,  some  difficulty  in  breathing  from  spasm  of  the 
larynx,  which  will  usually  be  relieved  by  an  anodyne,  such  as  a  full  dose  of  pare- 
goric. 

In  none  of  the  recovered  cases  has  there  been  any  impairment  of  the  voice. 


PRIZE  OFFERED  BY  THE  ALUMNI  ASSOCIATION  OF  THE  COLLEGE  OF 
PHYSICIANS  AND  SURGEONS  IN  THE  CITY  OF  NEW  YORK. 

The  Alumni  Association  of  the  College  of  Physicians  and  Surgeons  in  the  City  of 
New  York  offer  for  the  following  year  a  prize  of  Five  Hundred  Dollars,  open  for 
competition  to  all  Alumni  of  this  College.  It  will  be  awarded  to  the  best  medical 
essay  submitted,  if  deemed  sufficiently  meritorious,  upon  any  subject  which  the 
writer  may  select.  The  essay  in  order  to  compete  must  be  based  upon  Original 
Investigations.  Each  essay  must  be  marked  with  a  device  or  motto  and  accompanied 
by  a  sealed  envelope  similarly  marked  containing  the  name  and  address  of  the 
author.  Essays  must  be  submitted  to  the  Committee  on  or  before  February  15, 
1879.  They  may  be  sent  direct  to  any  of  the  Committee,  or  to  the  College,  care  of 
the  Faculty. 

The  Committee  coosists  of  Drs.  Henry  B.  Sands,  Wm.  H.  Draper,  and  Frank 
E.  Beckwith. 


THE 

AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES 

FOR  OCTOBER,  1878. 


CONTRIBUTORS  TO  THIS  VOLUME. 


JULIUS  ALTHAUS,  M.D.,  M.R.C.P.  Lond.,  Senior  Physician  to  Hospital  for  Epi- 
lepsy and  Paralysis,  Regent's  Park,  London. 
JOHN  ASHHURST,  Jr.,  M.D.,  Prof,  of  Clin.  Surg,  in  University  of  Pennsylvania. 
SAMUEL  ASHHURST,  M.D.,  of  Philaddphia. 
WALTER  F.  ATLEE,  M.D.,  of  Philadelphia, 
T.  H.  BALLERAY,  M.D.,  of  Pater  son,  New  Jersey. 
CLEMENT  RIDDLE,  M.D.,  Assistant  Surgeon  V.  S.  Xavy. 
JOHN  S.  BILLINGS,  M.D.,  Surgeon  U.  S.  Army. 
EDWARD  H.  BRADFORD,  M.D.,  of  Boston. 

CHARLES  STEDMAN  BULL,  M.D.,  Surgeon  to  New  York  Eye  Infirmary,  N.  Y. 
CHARLES  H.  BURNETT,  M.D.,  Aural  Surgeon  to  Presbyterian  Hospital,  Phila. 
SWAN  M.  BURNETT,  M.D.,  of  Washington,  D.  C. 
ELBRIDGE  G.  CUTLER,  M.D.,  of  Boston. 
EPHRAIM  CUTTER,  M.D.,  of  Cambridge,  Massachusetts. 
M.  J.  DE  ROSSET,  M.D.,  Assist.  Surg,  to  New  York  Eye  and  Ear  Infirmary. 
LOUIS  A.  DUHRING,  M.D.,  Clin.  Prof,  of  Skin  Diseases  in  University  of  Penna. 
AUSTIN  FLINT,  Jk.,M.D.,  Prof,  of  Physiology ,  BcUcvue  Hospital,  lied.  Col.,  N.  Y. 
W.  S.  FORBES,  M.D.,  Surgeon  to  tJie  Episcopal  Hospital,  PhiladelpJda. 
V.  P.  GIBNEY,  M.D.,  House-Surgeon  to  Hospital  for  Ruptured  and  Crippled,  N.  Y. 
WILLIAM  GOODELL,  M.D.,  Prof,  of  Clin.  Gynecology  in  University  of  Pennsylvania. 
SAMUEL  D.  GROSS,  M.D.,  LL.D.,  D.C.L.Oxox.,  Prof,  of  Surgery  in  Jefferson  Medi- 
cal College,  Philaddphia. 
F.  GUNDRUM,  M.D.,  of  Ionia,  Michigan. 
SAMUEL  HALL,  M.D.,  of  Reedsburgh,  Wisconsin. 
ROBERT  P.  HARRIS,  M.D.,  of  Philadelphia. 

GEORGE  C.  HARLAN,  M.D.,  Surgeon  to  Wills  [Ojitehalmic]  Hospital,  Philadelphia. 
HENRY  HA  RTSHORNE,  M.D.,  of  Philadelphia. 
EDGAR  HOLDEN,  M.D.,  of  Newark,  New  Jersey. 

JAMES  H.  HUTCHINSON,  M.D.,  Physician  to  the  Pennsylvania  Hospital. 

A.  B.  ISHAM,  M.D.,  Prof,  of  Physiology  in  Cincinnati  College  of  Med.  and  Surgery. 
MARY  PUTNAM  JACOBI,  M.D.,  of  New  York. 

CHARLES  KELSEY,  M.D.,  Assist.  Demonstrator  of  Anatomy  at  College  of  Physicians 

and  Surgeons,  N.  Y. 
WILLIAM  W.  KEEN,  M.D.,  Surgeon  to  St.  Mary's  Hospital,  Philadelphia. 
GEORGE  M.  LEFFERTS,  M.D.,  Clin.  Prof,  of  Laryngoscopy,  College  of  Physicians 

and  Surgeons,  New  York. 
MERRI WETHER  LEWIS,  M.D.,  of  Lenoir,  Tennessee. 
MICHAEL  J.  B.  MESSEMER,  M.D.,  of  New  York. 

MIDDLETON  MICHEL,  M.D.,  Prof,  of  Phijsiology  and  Histology  in  Medical  College 

of  State  of  South  Carolina. 
CHARLES  K.  MILLS,  M.D.,  Neurologist  to  the  Philadelphia  Hospital. 
S.  WEIR  MITCHELL,  M.D.,  Physician  to  the  Infirmary  for  Nervous  Diseases,  Phila. 
WILLIAM  F.  NORRIS,  M.D.,  Clinical  Prof,  of  Diseases  of  the  Eye  in  the  University 

of  Pennsylvania. 
W.  F.  MUHLENBERG,  M.D.,  of  Reading,  Pennsylvania. 
GEORGE  A.  PETERS,  M.D.,  Surgeon  to  New  York  Hospital,  New  York. 
F.  PEYRE  PORCHER,  M.D.,  Phys.  to  City  Hospital  Charleston,  South  Carolina. 

B.  LINCOLN  RAY,  M.D.,  of  PhiladelpMa. 
ISAAC  RAY,  M.D.,  of  Philadelphia. 

JOHN  J.  REESE,  M.D.,  Prof,  of  Med.  Jurisp.  and  Tot.  in  University  of  Penna. 
BEVERLEY  ROBINSON,  M.D.,  Lecturer  upon  Clinical  Medicine  at  BeUevue  Hospital 

Medical  College,  New  York. 
H.  S.  SCHELL,  M.D.,  Surgeon  to  Wills  [Ophthalmic]  Hospital,  Philadelphia. 
WHARTON  SINKLER,  M.D.,  Physician  to  Infirmary  for  Nervous  Diseases,  Phila. 
ROBERT  M.  SMITH,  M.D.,  Demonstrator  of  Physiology,  University  of  Pennsylvania. 
LOUIS  STARR,  M.D.,  Physician  to  the  Ejnscopal  Hospital,  Philadelphia. 
REUBEN  A.  VANCE,  M.D.,o/  Oallipolis,  Ohio. 

JAMES  C.  WHITE,  M.D.,  Professor  of  Dermatology  in  Harvard  University. 
FRANK  WOODBURY,  M.D.,  Physician  to  German  Hospital,  Philadelphia. 


TO  READERS  AND  CORRESPONDENTS. 


All  communications  .intended  for  insertion  in  the  Original  Department  of  this 
Journal  are  only  received  for  consideration  with  the  distinct  understanding  that 
they  are  sent  for  publication  to  this  Journal  alone,  and  that  abstracts  of  them 
shall  only  appear  elsewhere  subsequently,  and  with  due  credit.  Gentlemen 
favouring  us  with  their  communications  are  considered  to  be  bound  in  honour  to 
a  strict  observance  of  this  understanding. 

Contributors  who  wish  their  articles  to  appear  in  the  next  number  are  requested 
to  forward  them  before  the  1st  of  November. 

Compensation  is  allowed  for  original  articles  and  reviews,  except  when  illus- 
trations or  extra  copies  are  desired.  A  limited  number  of  extra  copies  (not 
exceeding  fifty}  will  be  furnished  to  authors,  provided  the  request  for  them  be 
made  at  the  time  the  communication  is  sent  to  the  Editors. 

The  following  works  have  been  received  :  — 

Yortrage  aus  dem  Gesammtgebiete  der  Au°:en-Heilkunde  fiir  Studirende  und  Aerzte. 
Von  Dr.  Ludwig  Mauthneb,  k.  k.  Universitat-Professor  in  Wien.  Erster  Heft.  Die 
Sympathischen  Augenleiden,  Weisbaden.  J.  F.  Bergmaxx.  New  York  :  B.  West- 
mann  &  Co.,  1878. 

Die  Osteoblastentheorie  auf  Normalen  und  Patbologischen  Gebiet.  Ueber  die  Veran- 
derung  des  Markes  der  langen  Rohrenknochen  hei  experimentell  erregter  EntzUndung 
eines  derselben.  Ueber  die  Nekrose  den  Knochen.  Von  Dr.  F.  Busch,  a.  6.,  Prof, 
dei-  Chirargie  au  der  Universitat  zu  Berlin. 

Drei  Falfe  von  Gesichtsueuralgie  dem  Nervenresection  geheilt  oder  gebessert.  Von 
Dr.  Carl  Fieber,  Docenten  dei^Chirurgie  an  der  Wiener  Universitat.    Berlin,  1878. 

Notes  on  the  Diseases  affecting  European  Residents  in  Japan.  By  Stuart  Elbridge, 
M.D.,  one  of  the  surgeons  of  the  General  Hospital  of  Yokohama.    Shanghai,  1878. 

Placentarreste  nach  Zeitgeburten.  Von  Alois  Graettixger,  aus  Milwaukee,  Wis. 
Munchen,  1878. 

Varicocele.    Yon  Nikolaus  Sexx.    Aus  Milwaukee,  Wis.    Munchen,  1878. 

On  Asthma:  its  Patbology  and  Treatment.  By  J.  B.  Berkart,  M.D.,  M.R.C.P. 
Lond.    London  :  J.  &  A.  Churchill,  1878. 

Contributions  to  the  Physiology  and  Pathology  of  the  Breast  and  its  Lymphatic 
Glands.  By  Charles  Creightox~,  M.B.,  Demonstrator  of  Anatomy  in  the  University 
of  Cambridge.    London  :  Macmillan  &  Co.,  1878. 

Guy's  Hospital  Reports.  Third  series,  vol.  xxiii.  London  :  J.  &  A.  Churchill,  1878. 

Aids  to  Chemistry.  Specially  designed  for  Students  preparing  for  Examinations. 
Part  II.  Inorganic'  The  Metals.  By  C.  E.  Armaxd  Semple,  B.A.,  M.D.,  Cantab. 
London  :  Bailliere,  Tindall  &  Cox,  1878. 

Phosphates  in  Nutrition,  and  the  Mineral  Theory  of  Consumption  and  Allied  Dis- 
eases.   By  M.  F.  Axdersox.    London  :  Bailliere,  Tindall  &  Cox,  1878. 

The  Numeration  of  Blood-Corpuscles,  and  the  Effect  of  Iron  and  Phosphorus  on  the 
Blood.    By  W.  Ft.  Gowers,  M.D. 

On  Giant  Urticaria.    By  J.  L.  Miltox.    London,  1878. 

Cholecystotomy  for  the  Removal  of  Gail-Stones  in  Dropsy  of  the  Gall-Bladder.  By 
J.  Mariox  Sims,  M.D.    London,  1878. 

A  Review  of  the  Past  and  Present  Treatment  of  Disease  of  the  Hip,  Knee,  and 
Ankle-Joints,  with  their  Deformities.    By  Hugh  Owex  Thomas.    Liverpool,  1878. 

Fownes'  Manual  of  Chemistry,  Theoretical  and  Practical.  Revised  and  corrected  by 
Hexrt  Watts,  B.A.,  F.R.S.  A  new  Am.  ed.  from  the  12th  Eng.  ed.  Edited  by 
Robert  Bridges,  M.D.    Philadelphia  :  Henry  C.  Lea,  1878. 

Anatomy,  Descriptive  and  Surgical.  By  Hexrt  Gray,  M.D.,  F.R.S.  With  an  In- 
troduction to  General  Anatomy  and  Development.  By  T.  Holmes,  M.A.,  Cantab. 
A  new  Am.  from  eighth  and  enlarged  Eng.  ed.  To  which  is  added  Landmarks,  Medi- 
cal and  Surgical.   By  Luther  Holdex,  F.R.C.S.   Philadelphia  :  Henry  C.  Lea,  1878. 

A  Clinical  History  of  the  Medical  and  Surgical  Diseases  of  Women.  By  Robert 
Barxes,  M.D.  Lond.,  Obstetric  Phys.  and  Lect.  on  Obstetrics  and  Dis.  of  Women  to 
St.  George's  Hosp.  Second  Am.  from  the  second  and  revised  Lond.  ed.  Philadelphia  : 
Henry  C.  Lea,  1878. 


312 


TO  READERS  AND  CORRESPONDENTS. 


Elementary  Quantitative  Analysis.  By  Alexander  Classen,  Prof,  in  the  RoyaJ 
Polytechnic  School,  Aix-la-Chapelle.   Translated  -with  additions  by  Edgar  F.  Smith, 

A.  M.,  Ph.D.,  Assist,  in  Analytical  Chemistry  in  the  Towne  Scientific  School,  Univ.  of 
Penna.    Philadelphia  :  Henry  C.  Lea,  1878. 

The  Antagonism  of  Therapeutic  Agents,  and  what  it  Teaches.  By  J.  Milxer 
Fothergill,  M.D.  Edin.,  Assist.  Phys.  to  West  London  Hosp.,  etc.  Philadelphia: 
Henry  C.  Lea,  1878. 

On  the  Therapeutic  Forces  :  An  Effort  to  Consider  the  Action  of  Medicines  in  the 
Light  of  the  Modern  Doctrine  of  the  Conservation  of  Force.  By  Thomas  J.  Mays, 
M.D.    Philadelphia  :  Lindsay  6c  Blakiston,  1878. 

Atlas  of  Skin  Diseases.    By  Louis  A.  Duhrixg,  M.D.    Part  IV.    Philadelphia  :  J. 

B.  Lippincott  6c  Co.,  1878. 

Studies  in  Pathological  Anatomy.  By  Francis  Delafield,  M.D.  Nos.  6,  7.  New 
York  :  Wm.  Wood  &  Co.,  1878. 

A  Practical  Treatise  on  the  Diseases  of  the  Ear,  including  the  Anatomy  of  the  Organ. 
By  D.  B.  St.  Johx  Roosa,  M.A.,  M.D.,  Prof,  of  Dis.  of  Eye  and  Ear  in  Univ.  of  City 
of  New  York,  etc.    New  York  :  William  Wood  6c  Co.,  1878. 

A  Practical  Treatise  on  the  Medical  and  Surgical  Uses  of  Electricity.  By  George 
M.  Beard,  A.M.,  M.D.,  and  A.  D.  Rockwell,  M.D.  2d  ed.,  revised,  enlarged,  and 
mostly  rewritten.    New  York  :  William  Wood  6c  Co.,  1878. 

Stricture  of  the  Male  Urethra;  its  Radical  Cure.  By  Fessexdex  N.  Otis,  M.D., 
Prof,  of  Genito-Urinarv  Dis.  in  Coll.  of  Phys.  and  Surgeons,  N.  Y.  New  York :  G. 
P.  Putnam's  Sons,  1878. 

Transactions  of  the  American  Gynecological  Society.  Vol.  2.  For  the  year  1S77. 
Boston  :  Houghton,  Osgood  &  Co.,  1878. 

Litholapaxj^  or  Rapid  Lithotrity  with  Evacuation.  By  Hexry  J.  Bigelow,  M.D. 
Boston  :  A.  Williams  6c  Co.,  1878. 

Antagonism  of  Alcohol  and  Diphtheria.  By  E.  N.  Chapmax,  A.M.,  M.D.  Brook- 
lyn, 1878. 

The  Value  of  Electrolysis  in  the  Treatment  of  Ovarian  Tumours.  By  Paul  F. 
Muxd£,  M.D.    New  York. 

Vascular  Tumours  of  the  Female  Urethra.  By  A.  Reeves  Jacksox,  M.D.  Chicago. 

On  the  Necessitv  of  Caution  in  the  Use  of  Chloroform  during  Labour.  By  William 
T.  Lusk,  M.D.    New  York. 

Certain  Symptoms  of  Nervous  Exhaustion.    By  George  M.  Beard,  M.D. 

Treatment  of  Diphtheria.    By  P.  F.  Whitehead,  M.D.    Vicksburg,  Miss. 

Carbolic  Acid  Injections  in  the  Treatment  of  Piles.  By  A.  B.  Cook,  M.D.  Louis- 
ville. 

The  Present  Status  of  the  Pathologv  of  Consumption  and  Tuberculosis.  By  J.  Hil- 
yard  Tyndall,  M.D.,  of  New  York  City.    New  York,  1878. 

Relative  Frequency  of  Colour-Blindness  in  Males  and  Females.    By  Joy  Jeffries, 

A.  M.,  M.D.    Cambridge,  1878. 

The  Identification  of  the  Human  Skeleton.  By  Thomas  Dwight,  M.D.,  of  Boston. 
Boston,  1878. 

On  Lying-in  Institutions,  especially  those  in  New  York.  Bv  Hexry  J.  Garrigues, 
M.D. 

Congenital  Absence  and  Accidental  Atresia  of  the  Vagina.    By  T.  A.  Emmet,  M.D. 

The  Hystero-Neuroses  with  Especial  Reference  to  the"  Menstrual  Hystero-Neurosis 
of  the  Stomach.    By  George  J.  Exgelmaxx,  M.D. 

The  Functions  of  the  Anal  Sphincters,  so-called.    By  James  R.  Chadwick,  M.D. 

Amputations  and  Excisions  of  the  Cervix  Uteri ;  their  Indications  and  Methods. 
By  J.  Byrne,  M.D. 

Variola  ;  its  Causes,  Nature,  and  Prophylaxis,  and  the  Dangers  of  Vaccination.  By 

C.  Spixzig,  M.D.    St.  Louis,  1878. 

Report  of  2000  Cases  of  Disease  in  Children  treated  at  the  Dewitt  Dispensary,  New 
York,  with  Notes.    By  P.  Bryxberg  Porter,  M.D.    New  York,  1878. 

Defective  Medical  Education  the  Chief  Obstacle  to  a  Proper  Appreciation  of  our 
Profession  by  the  Public,  and  what  our  Alma  Mater  is  doing  to  Remove  it.    Bv  W.  A. 

B.  '  Norcom,  M.D.    Philadelphia,  1878. 

On  the  Nature,  Origin,  History,  and  Public  Prophylaxis  of  Venereal  Diseases,  and 
the  Doctrines  of  Syphilis.    By  Thos.  Kexxard,  M.D.    St.  Louis,  1878. 

Neuralgia  and  its  Modern  Therapeusis.    By  James  Baird,  M.D.  Atlanta. 

The  Pith  of  the  Dried  Corn  Stalk  as  a  Uterine  Tent.  By  W.  T.  Goldsmith,  M.D. 
Atlanta. 

Report  on  Public  Hygiene  and  State  Medicine.  By  F.  W.  Hatch.  M.D.  Sacramento. 
The  Application  of  Pressure  in  Diseases  of  the  Uterus.  By  V.  H.  Taliaferro,  M.D. 
Atlanta.  _ 
The  Causation  of  Typhoid  Fever.    By  George  E.  Warixg,  Jr.    Cambridge,  1S7S. 
Hystero-Neurosis,  with  Cases.    By  G.  A.  Moses,  M.D.    St.  Louis.  1878. 
Urethral  Stricture.    By  Thomas  R.  Brown,  M.D.    Baltimore,  1878. 
Floating  Spleen.    By  Frederick  C.  Shattuck,  M.D.,  of  Boston. 


TO  READERS  AND  CORRESPONDENTS. 


313 


Eiffht  Cases  of  Intra-Larvngeal  Growths  removed  through  the  Natural  Passages. 
By  J.  H.  Hartman,  M.D.    Baltimore. . 

Certain  Symptoms  of  Nervous  Exhaustion.    By  Geoege  M.  Beabd,  M.D. 

Sound  and  the  Telephone.    By  Claeence  J.  Blake,  M.D.  Boston. 

On  the  Postural  Treatment  of  Tympanites  Intestinalis  following  Ovariotomy.  By 
Edward  W.  Jenks,  M.D.    New  York,  1878. 

Bibliotheca  Medica.    Cincinnati:  Robert  Clarke  &  Co.,  1878. 

Rectification  of  Abnormal  Foetal  Positions.  By  Thomas  Ryebson,  A.M.,  M.D. 
Newton,  N.  J. 

Address  before  the  American  Medical  Association.  By  T.  G.  Richaedson,  M.D., 
of  New  Orleans.    Philadelphia,  1878. 

Psoriasis  non  Syphilitica.    By  S.  H.  Stout,  M.D.    Roswell,  Ga. 

The  New  Treatment  for  Chorea.    By  John  Van  Bibbee,  M.D.   Baltimore.  1878. 

Double  Optic  Neuritis  and  Sloughing  of  the  Right  Cornea  accompanying  a  Sarcoma- 
tous Tumour  of  the  Ri°\ht  Side  of  the  Brain.  A  Case  of  Choroiditis  Exudativa.  By 
Swan  M.  Burnett,  M.D.    Washington,  D.  C.    New  York,  1878. 

Report  on  Public  Hygiene  in  Indiana.    By  Thad.  M.  Stevens,  M.D.  Indianapolis. 

A  Hy6tero-Psychosis.  The  Obstetric  Forceps.  By  Geo.  J.  Engelmann,  M.D. 
Saint  Louis,  1878. 

The  Soft  Palate.    By  Wis.  Abeam  Love,  M.D.    Atlanta,  1878. 

Medico-Lee-al  Evidence  relating  to  the  Detection  of  Human  Blood  presenting  the 
Alterations  of  Malarial  Fever.    By  Josefh  Jones,  M.D.    New  Orleans,  1878. 

Post  Nasal  Catarrh,  Tubercular  Laryngitis.    Bv  Wm.  Portee,  M.D.,  of  St.  Louis. 

Modern  Stimulation,  etc.    By  T.  J.  W.  Pray,  M.D.    Concord,  1878. 

On  Foeticide.    By  Henry  Gibbons,  Sr.,  M.D. 

Reflex  Symptoms  in  Hip  Disease.    By  Edward  H.  Bradford,  M.D.,  of  Boston. 
Address  before  the  Indiana  State  Medical  Society.    By  L.  D.  Wateeman,  M.D. 
Indianapolis,  1878. 

A  Case  of  Urinary  Suppression  in  Yellow  Fever  ;  treated  by  Super-oxygenated  Air 
and  Jaborandi.    By  W.  Hutson,  of  St.  Louis. 

The  Brain  and  Nervous  Svstem  in  their  Relations  to  Teaching  and  Learning.  By  J. 
C.  Reeve,  M.D.    Dayton,  1878. 

Strictures  of  the  Cervical  Canal.  By  A.  Fredrik  Eklund,  M.D.  Upsal,  Stockholm. 
Tmnslated  by  A.  Sibley  Campbell,  M.D.    Atlanta,  1878. 

Upon  the  Treatment  of  Strumous  Disease  by  what  may  be  called  the  Solfatara 
Method.    By  Horatio  R.  Storer,  M.D.,  Newport,  R.  I.    Boston,  1878. 

Battey's  Operation ;  Three  Fatal  Cases  with  some  Remarks  upon  the  Indications 
for  the  Operation.    By  George  J.  Engelmann,  M.D.    New  York,  1878. 

A  Conspectus  of  the  Different  Forms  of  Phthisis,  intended  as  an  Aid  to  Differential 
Diagnosis.    By  Roswell  Paek,  M.D.    Chicago,  1878. 

Further  Testimony  on  the  LTse  of  Large  Probes  in  the  Treatment  of  Strictures  of  the 
Nasal  Duct.    By  Samuel  Theobald,  M.D.    New  York,  1878. 

A  Paper  on  Intra-Laryngeal  Growths.  By  Clinton  Wagnee,  M.D.  Columbus,  1878. 

The  Prevention  of  Disease,  Insanity,  Crime,  and  Pauperism.  By  Nathan  Allen, 
M.D.    Boston,  1878. 

Transactions  of  the  Iowa  State  Medical  Society.    1877-78.    Des  Moines,  1878. 

Transactions  of  the  Rhode  Island  Medical  Society.    1877-78.    Central  Falls,  1878. 

Transactions  of  the  Mississippi  State  Medical  Association.    1878.    Jackson,  1878. 

Transactions  of  the  Medical  Association  of  Georgia.    1878.    Atlanta,  1878. 

Proceedings  of  the  Connecticut  Medical  Society.    1878.    Hartford,  1878. 

Transactions  of  the  South  Carolina  Medical  Association.   1878.    Charleston,  1878. 

Transactions  of  Medical  and  Chirurgical  Faculty  of  Maryland.  1878.  Baltimore,  1878. 

Transactions  of  the  Medical  Society  of  the  State  of  California.  1877  and  1878. 
Sacramento,  1878. 

Proceedings  of  the  Medical  Society  of  the  County  of  Kings.  July,  Aug.,  Sept.  1878. 
Proceedings  of  the  Academy  of  Natural  Sciences.    Jan.  to  April,  1878. 
Medical  Communications  of  Massachusetts  Medical  Society.  Vol.  xii.  No.  IV.  1878. 
Transactions  of  the  Medical  Society  of  the  State  of  New  York.  1878.  Syracuse,  1878. 
Transactions  of  Medical  Association  of  State  of  Missouri.    1878.    St.  Louis,  1878. 
Transactions  of  Medical  Association  of  Alabama.    1878.    Montgomery,  1878. 
Transactions  of  Medical  Society  of  State  of  North  Carolina,  1878.  Wilmington,  1878. 
The  American  Medical  College  Association.   Annual  Meeting.  1878.  Detroit,  1878. 
Annual  Reports  of  the  Supervising  Surgeon-General  of  the  Marine-Hospital  Service 
of  the  United  States  for  the  Fiscal  Years  1876  and  1877.    Washington,  1878. 
Report  of  the  Board  of  Health  of  the  City  of  Boston.    1878.    Boston,  1878. 
Report  of  the  State  Board  of  Health  of  the  State  of  Michigan.  1877.  Lansing,  1878. 

The  following  Journals  have  been  received  in  exchange : — 

Deutsches  Archiv  fur  Klinische  Medicin.  Bd.  XXL,  Heft  5  to  6.  Bd.  XXII.,  Heft 
1,2. 

Archiv  der  Heilkunde.    Bd.  XIX. ,  Heft  4. 


314 


TO  READERS  AND  CORRESPONDENTS. 


Centralblatt  fur  die  Medicinischen  Wissenschaften.    Xos.  23  to  36, 1878. 
Allgemeine  Wiener  Medizinische  Zeitung.    Nos.  23  to  36,  1878. 
Deutsche  Medicinische  Wochenschrift.    Xos.  23  to  35,  1878. 
Medizinische  Jahrbucher.    1878.    Heft  1. 
Medicinisch-Chirurgisches  Centralblatt.    Nos.  27  to  31,  1878. 
Upsala  Lokarelorenings  F6rhandline:ar.    Bd.  XIII.,  Xos.  5,  6,  7,  8. 
Bibliothek  fur  Larger.    Bd.  VIII.,  Heft  3. 
Nordiskt  Medicinskt  Archiv.    Bd.  X.,  Xo.  8. 

Annali  Universali  di  Medicina  e  Chirurgia.    Giugno,  Lusrlio.  Agosto,  187S. 
Giornale  Italiano  delle  Malattie  Veneree  e  della  Pelle.   Giueno,  Agosto,  1878. 
Commentario  Clinico  di  Pisa.    Maugio,  Guignio,  Luglio,  1878. 
L'Imparziale.    Xos.  11  to  16,  1878." 
Lo  Sperimentale.    Fascic.  6,  7,  8, 1878. 

La  Medicina  Contemporanea  Xuova  Rivista  Italiana  e  Straniera.    Giugno,  Luglio, 

Agosto,  1878. 

O  Correio  Medico  de  Lisboa.    Xos.  15,  16,  1878. 

Cronica  Medico-Quirurgica  de  la  Habana.    Junio,  Julio,  Agosto,  1S78. 
La  Gaceta  Cientifica  de  Venezuela.    Xos.  20  to  30,  1878. 
Archives  Generates  de  Melecine.    Juillet,  Aout,  Septembre,  1878. 
Revue  dcs  Sciences  Me  licales  en  France  et  de  l'Etran<rer.    Juillet,  1878. 
Revue  Mensuelle  de  Me  lecine  et  de  Chirorgie.    Juin,  Juillet,  Aout,  1878. 
Annalcs  de  Dermatologie  et  de  Syphiligraphie.   Tome  IX.,  Xo.  1. 
Annales  des  Maladies  de  l'Oreille  et  du  Larynx.    Juillet,  1878. 
Gazette  Hebdomadaire  de  Medeeine  et  de  Chirurgie.    Xos.  21  to  36, 1S78. 
L'Union  Medicale.    Xos.  67  to  105,  1878. 
Le  Progres  Medical.    Xos.  23  to  36,  1878. 
Le  Mouvement  Medical.    Xos.  21  to  27, 1878. 
L'Annee  Medicale.    Xos.  7,  8,  9,  1878. 

Revue  Scicntifique  de  la  France  et  de  rEtranger.    Xos.  50,  51,  52,  1878. 

Union  Medicale  et  Scientifique  du  Xord-Est.    Juin,  Juillet,  Aout,  1878. 

Revue  Internationale  des  Sciences.    Xos.  23  to  36,  1878. 

The  Retrospect  of  Medicine.    Jan.  to  July,  1878. 

The  Lancet.    July,  Aug.,  Sept.  1878. 

The  Medical  Times  and  Gazette.    July,  Aug.,  Sept.  1878. 

The  British  Medical  Journal.    July,  Aug.,  Sept.  1878. 

The  Medical  Examiner.     July,  Aug.,  Sept.  1878. 

The  London  Medical  Record.    June,  July,  August,  1878. 

The  Sanitary  Record.    July,  Aug.,  Sept.  1878. 

The  Practitioner.    June,  Julv,  August,  Sept.  1878. 

Brain,  July,  1878. 

The  Obstetrical  Journal  of  Great  Britain.    July,  Aug.,  Sept.  1878. 

Edinburgh  Medical  Journal.    June,  July,  Aug.,  Sept.  1878. 

The  Glasgow  Medical  Journal.    July,  Aug.,  Sept.  1878. 

The  Dublin  Journal  of  Medical  Science.    June,  Sept.  1878. 

The  Doctor.    Aug.,  Sept.  1878. 

The  Australian  Medical  Journal.    Oct.,  Xov.  1878. 

The  Australian  Practitioner.    April,  1878. 

The  usual  American  exchanges  have  been  received ;  their  individual  acknowledg- 
ment is  omitted  for  want  of  space. 


Communications  intended  for  publication,  and  books  for  review,  should  be  sent 
free  of  expense,  directed  to  Isaac  Hats,  M.D.,  Editor  of  the  American  Journal  of  the 
Medical  Sciences,  care  of  Mr.  Henry  C.  Lea,  Philadelphia.  Parcels  directed  as  above, 
and  (carriage  paid)  under  cover,  to  Mr.  Charles  J.  Skeet,  Bookseller,  Xo.  10  King 
William  Street,  Charing  Cross,  London,  will  reach  us  safely  and  without  delay. 

All  remittances  of  money  and  letters  on  the  business  of  the  Journal  should  be  ad- 
dressed exclusively  to  the  publisher,  Mr.  H.  C.  Lea,  Xo.  706  Sansom  Street. 

The  advertisement  sheet  belongs  to  the  business  department  of  the  Journal,  and  ail 
communications  for  it  must  be  made  to  the  publisher. 


CONTENTS 


OF 


THE  AMERICAN  JOURNAL 

OF 

THE  MEDICAL  SCIENCES. 

NO.  CLII.  NEW  SERIES. 
OCTOBER,  1878. 


ORIGINAL  COMMUNICATIONS. 
MEMOIRS  AND  CASES. 

A!iT.  PAGE 

I.  Laparotomy  in  a  Case  of  Extra-Uterine  Foetation ;  Operation  for  Re- 
moval of  Dead  Body  of  Child ;  Recovery  of  the  Woman.  By  Walter 
F.  Atlee,  M.D.,  of  Philadelphia.  With  Supplementary  Remarks  upon 
the  Importance  of  Operating  Early  ;  and  Dangers  of  the  Old  System  of 
Waiting  for  Nature.    By  Robert  P.  Harris,  M.D.,  of  Philadelphia.        .  321 

II.  On  the  Relations  between  Progressive  Ataxy  and  Spasmodic  Spinal 
Paralysis.    By  Julius  Althaus,  M.D.,  M.R.C.P.  Lond.,  Senior  Physician 

to  the  Hospital  for  Epilepsy  and  Paralysis,  Regent's  Park,  London.        .  338 

III.  The  Muscle  of  Accommodation,  and  its  Mode  of  Action.  By  M.  J. 
De  Rosset,  M.D.,  of  New  York,  Ophthalmic  Surgeon  to  Dispensary  of  the 
Church  of  the  Holy  Trinity,  Assistant  Surgeon  New  York  Eye  and  Ear 
Infirmary,  etc.  etc.        ..........  349 

IV.  Action  of  Phosphorus,  Alkalies,  and  Quinia  on  the  Globular  Richness 
of  the  Blood.  By  Elbridge  G.  Cutler,  M.D.,  and  Edward  H.  Bradford, 
M.D.,  of  Boston  367 

V.  Parotiditis,  or  Mumps  ;  A  Theory  of  its  Etiology,  and  the  Rationale  of 
the  Secondary  Manifestations,  or  so-called  Metastases.  By  A.  B.  Isham, 
M.D.,  Professor  of  Physiology  in  the  Cincinnati  College  of  Medicine  and 
Surgery.        ............  369 

VI.  Five  Cases  of  Spinal  Paralysis  of  the  Adult.  By  Wharton  Sinkler, 
M.D.,  Attending  Physician  to  the  Orthopaedic  Hospital  and  Infirmary  for 
Nervous  Diseases,  Philadelphia.     .       .       .        .       .       .       .  .379 

VII.  The  Diagnosis  of  Hip-Disease.  A  Clinical  Contribution.  By  V.  P. 
Gibney,  A.M.,  M.D.,  House-Surgeon  to  the  Hospital  for  the  Ruptured 
and  Crippled,  New  York  387 

VIII.  Syphilis  of  the  Conjunctiva.  By  Charles  Stedman  Bull,  A.M.,  M.D., 
Surgeon  to  the  New  York  Eye  Infirmary  and  to  Charity  Hospital,  New 
York   405 

IX.  Cause  and  Prevention  of  Squint.  By  H.  S.  Schell,  M.D.,  Surgeon  to 
Wills  [Ophthalmic]  Hospital,  and  Ophthalmic  Surgeon  to  St.  Mary's 
Hospital,  Philadelphia  418 

X.  A  Case  of  the  so-called  Xeroderma  (or  Parchment  Skin)  of  Hebra.  By 
By  Louis  A.  Duhring,  M.D.,  Professor  of  Skin  Diseases  in  the  University 
of  Pennsylvania,  Dermatologist  to  the  Philadelphia  Hospital,  and  Physi- 
cian to  the  Dispensary  for  Skin  Diseases  424 


316  CONTEXTS. 

ART.  PAGE 

XL  Vaso-Motor  and  Trophic  Affection  of  the  Fingers.  By  Charles  K. 
Mills,  M.D.,  Neurologist  to  the  Philadelphia  Hospital,  Lecturer  on  Elec- 
tro-Therapeutics in  the  University  of  Pennsylvania.       .       .       .  .431 

XII.  A  Case  of  Unilateral  Atrophy  of  the  Face,  accompanied  with  Slight 
Paralysis  of  the  Adductors  of  the  Vocal  Cords.  By  Beverley  Robinson, 
M.D.,  Lecturer  upon  Clinical  Medicine  at  the  Bellevue  Hospital  Medical 
College,  New  York.       .       .        .       .  437 

XIII.  Some  Experiments  on  the  Alleged  Poisonous  Action  of  Lead  Carbon- 
ate in  freshly  painted  Rooms.  By  Clement  Biddle,  M.D.,  Assistant  Sur- 
geon, U.  S.  Navy.         ..........  439 

XIV.  Spanish  Method  of  Using  the  Testicle  in  the  Radical  Cure  of  Inguinal 
Hernia.  By  Middleton  Michel,  M. I).,  Professor  of  Physiology  and  His- 
tology in  the  Medical  College  of  the  State  of  South  Carolina,  Charleston.  443 

XV.  Inversion  of  the  Bladder.  By  Reuben  A.  Vance,  M.D.,  of  Gallipolis, 
Ohio  *  445 

XVI.  Ligation  of  the  Common  Carotid  Artery  at  its  Lower  Third — Animal 
Ligature  used;  Unsuccessful;  Autopsy.  By  F.  Peyre  Porcher,  M.D., 
Associate  Physician  of  City  Hospital,  Charleston  ;  Professor  of  Materia 
Medica  and  Therapeutics,  and  of  Clinical  Medicine,  in  the  Medical  College 

of  the  State  of  South  Carolina  448 


REVIEWS. 

XVII.  The  Throat  and  its  Diseases.  With  one  hundred  Typical  Illustra- 
tions in  Colour,  and  fifty  "Wood  Engravings,  designed  and  executed  by  the 
Author,  Lennox  Browne.  F.R.C.S.  Ed.,  Senior  Surgeon  to  the  Central 
London  Throat  and  Ear  Hospital,  Surgeon  and  Aural  Surgeon  to  the  Royal 
Societv  of  Musicians,  etc.  8vo.  pp.  xii.,  351.  London:  Bailli&re,  Tin- 
dall  &*Cox,  1878. 

The  same.    Philadelphia  :  Henry  C.  Lea,  1878   451 

XVIII.  Daltonism  or  Colour-blindness. 

1.  Dangers  from  Colour-blindness  in  Railroad  Employes  and  Pilots.  By 

B.  Joy  Jeffries,  M.D.,  Ophthalmic  Surgeon  Massachusetts  Charitable 
Eye  and  Ear  Infirmary.  [Extracted  from  the  Report  of  the  Massa- 
chusetts State  Board  of  Health,  1878.]    8vo.  pp.  40.   Boston,  1878. 

2.  Incurability  of  Congenital  Colour-blindness.    By  B.  Joy  Jeffries,  M.D. 

Boston  Med.  and  Surg.  Journal,  March  28,  1878. 

3.  Le  Daltonisme.    MM.  J.  Delboeuf  et  W.  Spring,  Professeurs  &  l'Uni- 

versite  de  Lie^c    Revue  Scientifique  de  la  France  et  de  l'Etranger, 

23  Mars,  1878   466 

XIX.  Visions:  a  Study  of  False  Sight  (Pseudopia).  By  Edward  H. 
Clarke,  M.D.  With  an  Introduction  and  Memorial  Sketch  by  Oliver 
Wendell  Holmes,  M.D.  16mo.  pp.  315.  Boston:  Houghton,  Osgood  & 
Co.,  1878.     .    475 


ANALYTICAL  AND  BIBLIOGRAPHICAL  NOTICES. 

XX.  Transactions  of  the  American  Gynecological  Society.  Vol.  II.  For 
the  year  1877.    8vo.  pp.  697.    Boston:  Houghton,  Osgood  &  Co.  1878.  482 

XXL  The  Liverpool  and  Manchester  Medical  and  Surgical  Reports,  1877. 
Edited  by  John  Walkce,  M.D.  8vo.  pp.  xvi.  244.  Liverpool:  Adam 
Holden,  1878  _  .       .  .495 

XXII.  A  Monograph  of  Two  Hundred  and  Forty-eight  Ca^es  of  Lateral 
Lithotomy  Operations.  By  Rai  Ram  Narain  Dass  Bahadoor,  Lecturer  on 
Surgery  in  the  Campbell  Medical  School,  and  First  Surgeon  to  the  Camp- 
bell Hospital,  Calcutta.  8vo.  pp.  90.  Calcutta:  Thacker,  Spink  &  Co., 
1876-  500 


CONTENTS. 


317 


ART.  PAGE 

XXIII.  Cyclopaedia  of  the  Practice  of  Medicine.  Edited  by  Dr.  H.  Yon 
Ziemssen.  Vol.  XIV. — Diseases  of  the  Nervous  System  and  Disturb- 
ances of  Speech.  Prof.  A.  Eulenburg,  of  Greifswald  ;  Prof.  H.  Xoth- 
nagel,  of  Jena;  Prof.  H.  Von  Ziemssen,  of  Munich;  Prof.  F.  Jolly,  of 
Strasburg;  Prof.  A.  Kussmaul,  of  Strasburg;  and  Dr.  J.  Bauer,  of  Munich. 
Albert  H.  Buck,  M.D.,  of  New  York,  editor  of  American  edition.  8to. 

pp.  xx.,  893.    New  York:  William  Wood  &  Co.,  1877.        .       .  .503 

XXIV.  Vortraege  aus  dem  Gesammtgebiete  der  Augenheilkunde  fur  Studi- 
rende  und  Aerzte.  Von  Dr.  Ludwig  Mauthner,  K.  K.  Universitaets- 
Professor  in  Wien.  Erstes  Heft :  Die  Sympathischen  Augenleiden. 
Erste  Abtheilung :  Aetiologie,  Pathologic  8vo.  pp.  58.  Wiesbaden  :  J. 
F.  Bergmann.    New  York:  B.  Westermann  &  Co.,  1878. 

Lectures  on  Ophthalmology  for  Students  and  Physicians.  By  Dr.  Ludwig 
Mauthner,  Imperial- Royal  University  Professor  in  Vienna.  First  Part: 
Sympathetic  Diseases  of  the  Eye.    First  Section  :  Etiology,  Pathology.  507 

XXV.  Beitrage  zur  Praktischen  Augenheilkunde.  Von  Dr.  J.  Hirseh- 
berg,  Docent  an  der  Universitat  zu  Berlin.  Hefte  I.,  II.,  III.  Berlin: 
Hermann  Peters,  1876.    Leipzig:  Veit  &  Co.,  1877  and  1878. 

Contributions  to  Practical  Ophthalmology.  By  Dr.  J.  Hirschberg,  Lecturer 
in  the  University  of  Berlin.    Parts  I.,  II.,  and  III.       .        .        .  .510 

XXVI.  Ninth  Annual  Report  of  the  State  Board  of  Health  of  Massachu- 
setts.   8vo.  pp.  xl.,  529.    Boston,  1878   512 

XXVII.  Transactions  of  State  Medical  Societies. 

1.  Transactions  of  the  Medical  Association  of  Georgia,  April,  1878,  pp. 

279.    Atlanta,  Ga.,  1878. 

2.  Transactions  of  the  Mississippi  State  Medical  Association,  April,  1878, 

pp.  168.    Jackson,  Miss.,  1878. 

3.  Transactions  of  the  Iowa  State  Medical  Society,  May,  1877,  and  Jan. 

1878,  pp.  196.    Des  Moines,  1878. 

4.  Transactions  of  the  Vermont  Medical  Society,  June,  1877,  pp.  88.  St. 

Albans,  Vt.,  1878. 

5.  Transactions  of  the  Rhode  Island  *Medical  Society  for  1877  and  1878, 

pp.  49.    Central  Falls,  1878. 

6.  Proceedings  of  the  Connecticut  Medical  Society,  May,  1871,  pp.  234. 


Hartford,  Conn.,  1878   516 

XXVIII.  Report  on  Heating  and  Ventilation,  prepared  for  the  Trustees  of 
the  Johns  Hopkins  Hospital,  Baltimore.    By  John  S.  Billings,  Surgeon 

U.  S.  A.    8vo.,  pp.  93.    Baltimore,  1878  .523 

XXIX.  The  Pathology  of  Pulmonary  Consumption.^  Three  Lectures,  by 
T.  Henry  Green,  M.D.,  F.R.C.P.,  Physician  to  Charing-Cross  Hospital, 
and  Assistant  Physician  to  the  Hospital  for  Consumption  and  Diseases  of 
the  Chest,  Brompton.  12mo.,  pp.  viii.,  103.  London:  Henry  Renshaw, 
1878   524 


XXX.  Die  Enstehung  der  Gefahr  in  Krankheitsverlaufe,  mit  Besonderer 
Berucklichtigung  der  Diagnose  der  Gefahr,  ihrer  Prophylaxe,  und  Therapie. 
Von  Dr.  L.  M.  Politzer,  A.  O.  Professor,  Director  der  Ersten  OiFentlichen 
Kinderkrankeninstitutes  in  Wien.  8vo.,  pp.  xx.,  395.  Wien:  Wilhelm 
Braumviller,  1878. 

The  Occurrence  of  Danger  in  the  Course  of  Disease,  with  Special  Reference 
to  the  Recognition  of  the  Danger,  its  Prophylaxis,  and  Therapeutics.  By 
L.  M.  Politzer,  Director  of  the  Children's  Hospital  in  Vienna,  etc.         .  526 

XXXI.  Congenital  Occlusion  and  Dilatation  of  Lymph  Channels.  By 
Samuel  C.  Busey,  M.D.,  Professor  of  Theory  and  Practice  of  Medicine 
in  University  of  Georgetown,  etc.  8vo.,  pp.  xvi.,  187.  Xew  York: 
Wm.  Wood  &  Co.,  1878   527 

XXXII.  The  Antidotal  Treatment  of  Disease.  By  John  Parkin,  M.D., 
Corresponding  Fellow  of  the  Royal  Academies  of  Medicine  and  Surgery 
of  Madrid,  of  Barcelona,  and  of  Cadiz;  F.R.C.P.  Edinburgh,  etc.  Part 

I.    8vo.,  pp.  307.    London:  Hardwicke  and  Boyne,  1878.    .       .       .  528 


318 


CONTEXTS. 


ART.  PAGE 

XXXIII.  Physics  of  the  Infectious  Diseases.  Comprehending  a  Discussion 
of  Certain  Physical  Phenomena  in  Connection  with  the  Acute  Infectious 
Diseases.  By  C.  A.  Logan,  A.M.,  M.D.  12mo.  pp.  212.  Chicago: 
Jansen,  McClurg  &  Co.,  1878.       .       .        .        .       .       .       .    C  529 

XXXIV.  Atlas  of  Skin  Diseases.  By  Louis  A.  Duhring,  M.D.,  Professor 
of  Skin  Diseases  in  the  Hospital  of  tile  University  of  Pennsylvania  ;  Physi- 
cian to  the  Dispensary  for  Skin  Diseases,  Philadelphia,  "etc.  Part  IV. 
Philadelphia:  J.  B.  Lippincott  &  Co.,  1878.   531 

XXXV.  Anatomy,  Descriptive  and  Surgical.  By  Henry  Gray,  F.R.S. 
With  an  Introduction  on  General  Anatomy  and  Development  Bv  T. 
Holmes.  A  new  American  from  the  eighth  English  edition.  To  which  is 
added  Landmarks,  Medical  and  Surgical.  By  Luther  Holden,  F.R.C.S. 
Imperial  8 vo.  pp.  983.    Philadelphia:  H.  C.  Lea,  1878.        .       .  .532 

XXXVI.  Abbreviations  of  Titles  of  .Medical  Periodicals  to  be  u*ed  in  the 
Subject- Catalogue  of  the  Library  of  the  Surgeon-General's  Office.  Im- 
perial 8vo.  pp.  vi.,  9G.    Washington:  Government  Printing  Office,  1878.  532 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERI  E  SIN  T  II  E 
MEDICAL  S  C I E  X  C  E S . 

Anatomy  axd  Physiology. 

page  page 
On  the  Relative  Size  of  the  Tra-         Function  of  the  Eustachian  Tube, 
chea  and   Bronchia.  /  By   M.  By  Dr.  Hartmann.    .       .        .  536 

Marc  See.        .  533  Glycogen.    By  Dr.  Abeles.         .  537 

Supernumerary  Mammae.  By  Prof. 
Leichtenstern.  ....  534  1 


Materia  Medica  and  Therapeutics. 


The  Physiological  Action  of  Purga- 
tives.   By  L.  Brieger.      .        .  538 

Subnitrate  of  Bismuth.  By  Prof. 
Gubler.     .       .       .  .  538 

Oil  of  Rosemary.  By  Prof. 
Kohler  and  Herr  Schreiber.      .  539 

Comparison  of  Opium,  Belladonna, 
and  Aconite.  BvM.  Jules  Simon.  539 

Butyl  Chloral  *By  ?rof.  Lieb- 
reich.       .....  540 

Misuse  of  Bromide  of  Potassium. 
Bv  Boetto-er.     ....  541 


Therapeutic  Action  of  Iodoform. 

By  Dr.  Moleschott  .  .  .542 
Action  of  Pilocarpin.    By  Dr.  A. 

Loesch.     .....  543 

Action  of  Muriate  of  Pilocarpin  in 

Children.  By  Dr.  Demme.  .  543 
Action  of  Pilocarpin  and  Cotoin. 

By  Dr.  Clcetta.  .  .  .544 
Therapeutic  Uses  of  Coto.   By  Dr. 

Fronmuller.      .       .  .  544 


CONTENTS. 


319 


Medicine. 


page 

Local  Temperature.  By  M.  Peter.  546 
Ero-ot  in  Tvphoid  Fever.    By  M. 

Siredey.   .       .       .  .  546 

Peripheral    Hysteria.     By  Prof. 

Lasegue.  .       .       .       .  .547 

Death  from  Goitre.  By  Prof.  Rose.  548 
Tartar  Emetic  in  Pneumonia.  By 

Prof.  Hardy.  .  .  .  .548 
Sudden  Death  by  Embolism.  By 

Dr.  Terrillon.  .       .       .  '.549 


PAGE 

Diseases  of  the  Diaphragm.  By 

Mr.  Callender.  .  .  .  .551 
Paracotoin   in   Cholera.    By  Dr. 

Balz.        .....  553 

The  Diagnosis  and  Treatment  of 

Intestinal  Obstruction.    By  Mr. 

Jonathan  Hutchinson.  .  .  553 
Myositis  Ossificans.    By  Dr.  Nico- 

ladoni.      .  "  .        .        .  556 

A  New  Parasitic  Disease  of  the 

Hair.    By  M.  Desenne.    .        .  556 


Surgery. 


Septic  and  Aseptic  Wound-Fevers. 
By  Prof.  Yolk  maun  and  Dr. 
Alfred  Genzmer.      .       .  .557 

Occurrence  of  a  Pustular  Eruption 
in  Pytemic  Cases.  By  Mr.  H.  C. 
Cameron.         .       .       .  .559 

Cancer.    By  Prof.  Esmarch.        .  560 

Chloroma.    By  Dr.  Huber.  .  561 

Extirpation  of  the  Larynx ;  Arti- 
ficial Vocal  Apparatus.  By  Dr. 
George  Wegner.       .       .  .562 

Gunshot  Wound  of  the  Chest ;  Re- 
section of  the  Clavicle  and  five 
Ribs.    By  Dr.  Schneider.         .  562 

Gastrotomy!    By  Dr.  Otto  Risel.  563 

Cholecystotomy  in  Dropsy  of  the 
Gall- Bladder.  By  Dr.  J.  Marion 
Sims.       .....  565 

Enterostomy.    By  M.  Surmay.    .  565 

ForeignBody  in  the  Sigmoid  Flex- 
ure ;  Successful  Removal.  By 
Dr.  Studsgaard.       .       .       .  566 

Treatment  of  Hydrocele  by  Incision 
performed  Antiseprically.  By 
Dr.  Genzmer.   .        .        .  .567 

Ero;otin  in  Diseases  of  the  Bladder. 
By  Dr.  Molfese.        .       .       .56  7 

Syphilitic  Stricture  of  the  Rectum  ; 


Rectotomy  by  a  new  Operation. 
By  M.  Ti'elat  568 

Dupuytren's  Contraction  of  the 
Fingers.  By  Mr.  William  Adams.  569 

Sequel  to  a  Case  of  Aneurism  of  the 

.  Aorta,  and  the  Innominate,  Sub- 
clavian, and  Carotid  Arteries, 
treated  by  the  Double  Distal  Li- 
gature. By  Mr.  Richard  Barwell.  570 

Reunion  and  Restoration  of  Divided 
Nerves.     By  Mr.  Wheelhouse.  570 

Severe  Injun-  of  the  Axilla  during 
Reduction  of  a  Dislocated  Hu- 
merus.   By  Mr.  Thomas  Smith.  572 

Arthritis  Secondary  to  Acute  Mye- 
litis.   By  M.  Tallin.        .        .  572 

Dislocation  of  the  Muscles  and  their 
Treatment.  By  Mr.  Geo.  W. 
Callender.         .       .       .  .573 

Muscular  Necrosis.  By  Dr.  Liicke.  574 

Effect  of  Posture  on  the  Peripheral 
Circulation.    By  Mr.  Lister.     .  574 

Application  of  the  Poro-Plastic  Felt 
Jacket.    By  Mr.  Wm.  Adams.  576 

Varicose  Ulcer  and  its  Treatment. 
By  Mr.  John  Gay.    .       .  .577 

The  Transplantation  of  Tissues. 
By  Dr.  Zahn  577 


Ophthalmology  and  Otology. 

Iodoform  in  Eye-Disease.    By  Mr.        I  Daltonism ;    Sanitary  Precautions 
Patrick  J.  Hayes.     .        .        .578      and  Preventive  Measures.  By 

Case  of  Gummy  Tumour  of  the  M.  A.  Fabre.   .       .        .  .579 

Conjunctiva.    By  Dr.  Albrecht 
Berger.     .       .       .       .  .578 


Midwifery  and  Gynecology. 


Induction  of  Premature  Labour. 

By  Dr.  Schauta.  .  .  .579 
The   Revolutions   of   the  Foetal 

Head  in  Passing  through  a  Brim 


contracted  only  in  the  Conjugate 
Diameter.  By  Dr.  Matthews 
Duncan.   .....  580 


320 


CONTENTS. 


PAGE 

The  Etiology  of  Face  Presentations. 

By  Dr.  Mayr  581 

The  Treatment  of  Sore  Nipples. 

By  Dr.  Steiner.  .  .  .583 
Anatomical    Researches    on  the 


PAGK 

Causes    of    Sterility.      By  F. 

Winckel.  .       .  .       .  583 

Mr.  Spencer  Wells  on  Ovariotomy.  583 
Catgut  Sutures  in  Cesarean  Section. 

By  Dr.  E.  W.  Jenks.       .       .  585 


Medical  Jurisprudence  and  Toxicology. 

Examination   of    Seminal    Stains        ]  Malformations  of  the  Hymen  in 
found  on  the  Wooden  Floor  of  a  their  Relation  to  Legal  Medicine. 

Room.    By  Dr.  Gallard.  .       .  586  I     By  Dr.  Delens.        .       .       .  586 


AMERICAN  INTELLIGENCE. 

Original  Communications. 

Femoral  Hernia  Strangulated  on  its        I     very.  By  G.  H.  Balleray,  M.D., 
first  descent;    operation;    reco-        (     of  Patterson,  New  Jersey.        .  581 


Domestic  Summary. 


Induction  of  Premature  Labour  in 
the  Albuminuria  of  Pregnancy. 
By  Dr.  Fordyce  Barker.  .       .  589 

Treatment  of  Eczema  Rubrum  by 
means  of  Glycerole  of  the  Suba- 
cetate  of  Lead.  By  Drs.  Duhr- 
ing  and  Van  Harlingen.    .  .589 

Ligation  of  the  Lingual  Artery  near 


its  Origin,  as  a  Preliminary  Pro- 
cedure in  the  Extirpation  of  Can- 
cerous Disease  of  the  Tongue. 
By  Dr.  George  F.  Shrady.  .  590 
The  Unequal  Length  of  Normal 
Limbs  shown  by  Measurement  of 
the  Skeleton.  By  Dr.  John  B. 
Roberts  590 


THE 


AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES 

FOR  OCTOBER,  187  8. 


Article  I. 

Laparotomy  in  a  Case  of  Extra-Uterine  Fetatiox;  Operatiox  for 
Removal  of  Dead  Body  of  Child;  Recovery  op  the  Woman.  By 
Walter  F.  Atlee,  M.D.,  of  Philadelphia.  With  Supplementary  Re- 
marks upon  the  Importance  of  Operating  Early;  and  Dancers  of 
the  Old  System  of  Waiting  for  Nature.  By  Robert  P.  Harris, 
M.D.,  of  Philadelphia. 

I  ay  as  consulted  on  September  5, 1877,  by  Mrs.  M.  0.,  of  Germantown, 
on  account  of  the  irritable  condition  of  her  stomach.  She  was  a  native 
of  Ireland,  came  to  this  country  when  she  was  nine  years  of  age,  was  then 
thirty-five,  and  had  been  married  sixteen  years.  She  had  always  been 
perfectly  regular  in  her  menstrual  discharge  until  the  previous  April,  since 
when  she  said  she  had  been  irregular.  On  the  24th  of  May  there  was 
considerable  hemorrhage,  and  after  that  she  had  seen  nothing.  After  ex- 
animation  I  told  her  I  thought  her  to  be  pregnant.  I  advised  the  use  of 
effervescing  salt  of  pepsin,  bismuth,  and  strychnia  for  sickness  of  stomach. 

On  the  13th  of  April  following,  she  came  to  my  office.  From  her  con- 
dition and  history  I  then  believed  her  to  be  carrying  in  the  abdominal 
cavity,  outside  of  the  womb,  a  child  that  had  come  to  full  term  in  January, 
when  the  child  had  died.  The  body  was  in  the  lower  part  of  the  belly, 
placed  transversely,  the  back  forwards,  and  the  head  on  the  left  side.  I 
advised  her  to  wait  until  symptoms  of  blood-poisoning  should  come,  when 
this  body  should  be  removed ;  otherwise  that  nature  was  not  to  be  inter- 
fered with  at  all,  until  a  channel  was  indicated  through  which  she  was 
endeavouring  to  get  rid  of  this  body,  and  then  the  patient  was  to  be  helped. 
An  operation  then  would  shorten  the  duration  and  the  suffering  of  the 
eliminative  process ;  it  was  one  of  but  little  danger,  and  a  source  of  great 
advantage. 

The  patient  came  to  see  me  one  month  afterwards,  and  in  the  mean 
while  I  had  become  convinced  that  this  advice  was  not  good,  but  that  the 
body  should  be  removed  without  delay.    When  this  was  told  her,  and  an 
No.  CLII  Oct.  1878.  21 


322  Laparotomy  in  a  Case  of  Extra-uterine  Foetation. 


immediate  operation  proposed,  she  eagerly  gave  her  consent.  Her  pulse 
was  then  109°,  but  there  were  no  decided  symptoms  of  purulent  infection. 

On  the  lGth  of  May  the  patient  came  to  this  city  to  the  room  prepared 
for  her  in  the  St.  Joseph  Hospital ;  after  this  no  food  was  allowed  to  be 
taken  except  barley  water;  on  the  17th  in  the  evening  a  dose  of  oil 
was  administered  ;  on  the  morning  of  the  18th  10  drops  of  McMunn's 
elixir  of  opium  were  given  ;  an  injection  thoroughly  emptied  the  lower 
bowel,  and  at  11  o'clock,  after  taking  a  drink  of  two  ounces  of  whiskey, 
the  patient  was  placed  on  the  operating  table  and  chloroformed.  An  inci- 
sion six  inches  in  length,  beginning  one  inch  above  the  navel,  was  made 
in  the  linea  alba;  the  peritoneum  was  found  thickened  and  vascular, 
but  not  with  large  bloodvessels ;  it  reminded  me  of  inflamed  dura  mater, 
though  not  quite  so  thick.  This  opened,  a  liquid  like  pea  soup,  about  one 
and  a  half  pints  in  quantity,  came  out,  and  the  child's  body  showed  itself, 
and  was  pulled  out  with  little  trouble  breech  foremost.  The  cavity  in 
which  it  was  contained  was  cleaned  out  by  sponging ;  at  the  bottom  a 
knuckle  of  intestine  showed  itself,  about  two  inches  in  length,  and  less  than 
one  inch  in  breadth.  With  this  exception  the  dead  body  of  the  child, 
which  weighed  four  pounds  and  two  ounces,  appeared  to  have  been  cut  off 
from  the  rest  of  the  contents  of  the  abdomen  by  a  continuous  membrane 
of  greater  or  less  thickness.  No  further  investigation  was  made  of  the 
state  of  things.  The  umbilical  cord  was  cut  so  that  about  four  inches 
hung  out  of  the  lower  part  of  the  wound  ;  alongside  of  it  a  drainage  tube 
of  India  rubber  was  placed,  the  wound  was  sewed  up,  and  the  usual  dress- 
ings applied.  After  removal  to  bed  a  quarter  grain  of  morphia  in  Magen- 
die's  solution  was  injected  under  the  skin  of  the  arm. 

After  the  operation,  with  the  exception  of  the  injection  just  mentioned, 
opium  was  given  only  three  times,  and  then  by  enema  in  the  form  of 
McMunn's  elixir,  together  with  bromide  of  potassium,  for  the  purpose  of 
producing  sleep,  on  the  19th,  the  21st,  and  the  25th.  She  was  allowed 
to  pass  her  urine  as  she  wished,  in  the  bed-pan  ;  after  the  31st,  she 
was  allowed  to  get  out  of  bed  for  this  purpose.  On  the  24th  she  had 
her  bowels  moved  for  the  first  time  ;  using  the  bed-pan.  For  the  second 
time  on  the  31st.  For  the  first  four  days,  on  account  of  sickness  of 
stomach,  which  lasted  two  days,  and  hiccough  that  lasted  four,  she  was 
nourished  by  injections  of  beef-essence — two  ounces  being  given  every 
four  hours.  After  that  time  she  used,  in  the  usual  way.  mutton  soup  and 
milk ;  on  the  24th  ate  some  bread,  on  the  26th  beefsteak,  and  by  degrees 
was  allowed  her  ordinary  food. 

The  pulse  after  the  operation  was  generally  about  105  ;  the  tempera- 
ture was  never  noticed  above  the  normal  standard.  The  drainage-tube 
was  removed  two  days  after  the  operation.  The  discharge  for  some  two 
days  had  particles  of  caseous  matter  in  it,  afterwards  it  became  a  healthy 
creamy  pus.  The  cord  dropped  on  the  24th.  On  the  28th  while  seated 
in  bed,  about  a  teacupful  of  healthy  pus  suddenly  came  from  the  vagina. 
By  the  touch  I  could  find  no  orifice  whence  this  came.  This  vaginal  dis- 
charge, though  very  small  in  quantity,  continued  for  five  days.  On  the  3d 
of  June  and  for  five  days  afterwards,  shreds  of  stuff  resembling  a  breaking 
down  membrane  were  discharged,  and  as  they  did  so.  a  body  about  the 
size  of  a  small  fist,  in  the  left  iliac  fossa,  gradually  disappeared. 

On  the  13th  the  patient  went  to  her  home  in  Germantown  in  very  good 
health,  a  few  drops  of  pus  still  coming  from  the  wound,  but  the  discharge 
diminishing  daily.  "W.  F.  A. 


1878.]        Laparotomy  in  a  Case  of  Extra-uterine  Foetation  323 

Of  the  three  varieties  of  puerpero-abdominal  surgery,  viz.,  the  Csesarean 
section,  the  abdominal  section  after  uterine  rupture,  and  the  same  in  extra- 
uterine pregnancy,  the  third  has  been  the  most  rarely  performed,  and  has 
only  quite  recently  begun  to  attract  attention ;  especially  as  an  operation 
to  be  resorted  to  early,  and  as  an  elective  procedure.  There  is  some  con- 
fusion in  the  classification  of  cases  and  operations ;  but  I  do  not  propose 
to  alter  it  here.  The  abdominal  pregnancy  is  called  primary,  when  devel- 
oped originally  in  the  cavity  of  the  abdomen  ;  and  secondary ',  when  the 
ovum  or  foetus  has  escaped  from  the  original  cyst  and  become  subsequently 
developed  as  a  ventral  foetation.  The  operation  is  also  primary,  if  per- 
formed during  the  life  of  the  foetus,  and  secondary,  if  after  its  death,  no 
matter  whether  recent  or  remote.  We  have,  therefore,  a  case  and  opera- 
tion both  termed  secondary ;  but  the  latter,  early  and  elective. 

In  view  of  the  happy  termination  of  the  operation,  it  is  a  satisfaction 
to  me  to  reflect  upon  the  fact  that  I  recommended  its  performance  both  to 
surgeon  and  patient,  and  advised  as  early  a  resort  to  the  knife  as  practi- 
cable, confirming  my  opinion  by  reference  to  several  of  the  cases  which 
are  referred  to  in  this  paper.  The  patient  readily  assented,  although 
she  had  been  advised  against  an  early  operation,  and  knew  that  she  ran 
much  risk  of  her  life  ;  but  she  also  knew  that  it  was  unsafe  to  remain  as 
she  was.  As  her  days  were  unhappy  and  nights  often  miserable,  by  reason 
of  suspense  and  suffering,  she  was  anxious  to  be  operated  upon. 

Progressive  surgery  has,  within  a  few  years,  overcome  in  a  measure 
many  of  the  deep-seated  prejudices  of  the  profession  against  the  several 
forms  of  operative  interference,  considered  for  a  long  period  to  be  of  them- 
selves almost  necessarily  fatal ;  and  in  no  one  form  is  this  more  apparent 
than  in  that  which  involves  the  once  much-dreaded  incision  into  the  abdo- 
minal cavity.  The  progress  made  in  ovariotomy,  and  its  unforeseen  suc- 
cess in  saving  life,  has  led,  and  is  gradually  leading  to  greater  boldness 
with  confidence,  in  other  abdominal  operations.  What  would  have  been 
considered  recklessness  a  few  years  ago,  is  coming,  by  reason  of  accumu- 
lated successes,  to  be  regarded  not  only  as  legitimate  but  advisable ;  and 
the  chief  obstacle  at  the  present  time  appears  to  lie,  not  so  much  in  the 
danger  of  peritonitis,  or  septic  infection,  as  in  the  difficulties  of  making  an 
unquestionable  diagnosis.  Could  tubal  pregnancy  be  positively  recognized 
at  the  time  of  rupture  in  the  early  months,  we  believe  it  would  not  be 
long  before  some  bold  operator  would  venture,  and  possibly  with  success, 
to  open  the  abdomen  of  a  woman,  secure  the  bleeding  vessels,  or  clamp 
the  entire  cyst,  and  evacuate  the  lost  blood.  This  has  never  been  done, 
and  has  but  recently  been  condemned  at  a  discussion  on  the  part  of  high 
authorities  in  London ;  but  it  may  yet  be  accomplished  if  the  diagnosis 
can  be  satisfactorily  determined  and  in  time  for  the  operation.  Women 
have  lived  a  number  of  hours,  and,  in  some  instances,  several  days  after 
the  bursting  of  a  tubal  cyst,  when  of  so  small  a  size  that  the  operation 


324 


Laparotomy  in  a  Case  of  Extra-uterine  Foctation. 


[Oct. 


might  have  succeeded.  I  once  reported  the  case  of  a  lady  who  died  in 
twenty-one  hours  after  the  cyst  burst,  in  whom  the  operation  might  have 
been  easily  performed.  The  symptoms,  clearly  to  my  mind,  although  they 
did  not  to  others  present,  indicated  rupture,  which  I  located  in  the  right 
Fallopian  tube,  and  proved  by  autopsy  to  be  correct  ;  but  this  diagnosis 
was  only  inferential,  and  therefore  not  sufficiently  reliable  to  warrant  an 
operation,  even  if  it  had  been  thought  of,  which  it  was  not,  as  the  case 
occurred  in  1857.  What  was  then  in  a  measure  conjectural,  although 
based  upon  well-known  evidences,  may,  under  improved  methods  of  diag- 
nosis, in  time  become  reliable.  So  many  mistakes  have  been  made  by 
men  of  great  fame,  in  their  hurry  of  business,  that  it  becomes  necessary 
in  avoiding  their  errors,  to  secure  a  clear  clinical  history  of  any  given 
case,  and  then  examine  it  with  all  the  most  approved  and  reliable  methods 
known  to  science.  What  is  known  as  hypogastric  or  pelvic  colic,  accom- 
panied by  vomiting,  and  possibly  fainting,  with  symptoms  of  collapse,  fol- 
lowed by  recovery,  should  make  an  attending  physician  suspect  a  tubal 
pregnancy,  and  put  him  upon  his  guard  for  a  more  severe  attack  ending 
in  rupture,  or  prepare  him  for  dealing  with  a  misplaced  pregnancy  at  an 
advanced  period,  and  keep  him  from  falling  into  the  error  of  believing 
that  he  has  in  hand  an  ovarian,  or  possibly  a  malignant  tumour.  Pallia- 
tion and  the  sound  are  very  important  in  determining  the  nature  of  abdo- 
minal tumours  suspected  of  having  a  pelvic  origin  ;  but  they  have  led 
wise  men  into  error,  when  the  patient's  history  had  not  been  properly 
taken  or  regarded.  It  may  be  well  to  ignore  the  statements  of  a  stupid 
woman  as  to  her  own  case  ;  but  there  are  patients  whose  accounts  of  their 
past  symptoms  are  remarkably  clear,  connected,  and  valuable,  as  in  the 
clinical  history,  now  to  be  given,  of  Dr.  Walter  F.  Atlee's  case. 

Mrs.  O.,  married  at  20,  and  although  regular,  did  not  conceive  for  fifteen 
years,  when  her  menses  ceased,  and  she  presumed  herself  pregnant,  their 
last  appearance  dating  April  loth,  1877.  At  the  end  of  the  sixth  week 
she  was  attacked  with  a  profuse  hemorrhage,  lasting  seven  days,  and 
thought  she  had  miscarried,  as  she  passed  a  membranous  substance  which 
she  said  "looked  like  a  piece  of  skin,"  such  as  she  had  never  discharged 
on  any  former  occasion,  which  was  no  doubt  the  decidua. 

Soon  the  usual  signs  of  pregnancy  made  their  appearance,  and  her 
mammae  commenced  to  develop  and  become  painful.  Pains  in  the  ab- 
domen were  now  experienced,  and  one  morning,  in  the  act  of  rising  from 
bed,  she  had  a  very  severe  attack  of  pain,  followed  by  vomiting,  and 
remained  sick  for  four  or  five  days,  but  without  medical  advice.  This 
pain  was  low  down  in  the  left  side  within  the  hip-bone,  and  evidently  in 
the  pelvis. 

On  June  30th,  1877,  when  presumed  to  be  ten  weeks  pregnant,  she  was 
seized  with  vomiting,  followed  immediately  by  a  very  severe  pain  in  the 
same  locality  as  before,  accompanied  by  a  sensation  of  tearing,  as  if  some- 
thing had  given  way,  and  followed  by  another  feeling,  indicating  that  a 
body  had  fallen  and  was  in  some  way  pressing  upon  the  bladder,  creating 
a  desire  to  urinate,  and,  at  the  same  time,  interfering  with  the  ready  pas- 


1878.] 


Laparotomy  in  a  Case  of  Extra-uterine  Foetation. 


325 


sage  of  the  fluid.  This  attack,  which  was  no  doubt  one  of  rupture  of  an 
extra-uterine  foetal  cyst,  and,  in  all  probability,  in  some  part  of  the  left 
Fallopian  tube,  in  which  such  early  accidents  are  most  apt  to  occur,  was 
followed  by  symptoms  of  collapse,  ending  in  violent  peritonitis,  the  abdo- 
men being  much  distended,  painful  to  touch,  and  sensitive  throughout, 
while  the  uterus  was  too  tender  to  admit  of  the  vaginal  touch.  After 
being  considered  in  much  danger  for  several  days,  she  began  to  improve, 
and,  at  the  end  of  a  week,  was  well  enough  to  be  removed  upon  her  bed 
to  a  farm  at  a  short  distance  from  her  residence,  where  she  soon  in  a  mea- 
sure recovered. 

Here,  in  two  weeks  more,  she  had  a  third  attack  of  pain  but  differently 
located,  associated  with  vomiting  and  fainting  turns,  which  continued  for 
three  days,  during  which  she  was  treated  with  hypodermic  injections  of 
morphia  and  food  enemata.  After  this,  she  had  sick  turns,  difficulty  in 
urination,  and  flying  pains,  lasting  through  the  summer  and  down  to  Sep- 
tember 5th,  when  she  first  felt  the  movement  of  the  foetus.  She  was 
also  affected  with  lameness  in  the  left  hip-joint,  which  had  a  sore  feeling, 
as  if  inflamed. 

When  quickening  took  place,  she  was  about  4-|  months  advanced  in  her 
pregnancy;  but  the  sensation  was  entirely  abnormal  in  location,  as  she 
found  by  consulting  some  of  her  friends  who  had  borne  children  naturally. 
The  motion  of  the  foetus  was  felt  low  down  in  the  left  side  of  the  pelvis 
near  the  rectum,  and  sometimes  further  forward,  near  the  bladder;  or,  as 
she  expressed  it,  "  the  baby  seemed  to  be  right  in  the  seat,  sometimes 
back,  near  the  backbone,  and  sometimes  in  front." 

As  gestation  advanced,  the  movements  of  the  foetus  became  more  and 
more  decided,  and  the  location  higher  and  higher,  until,  when  she  turned 
in  bed,  she  could  distinguish  the  sensation  of  a  body  moving  from  side  to 
side  within  her  abdomen.  At  last  the  foetal  motions  became  so  vigorous 
as  sometimes  to  wake  her  out  of  sleep ;  her  breasts  enlarged  until  milk 
was  secreted  in  them  ;  her  abdomen  became  very  large  and  pendulous,  so 
as  to  strike  upon  her  thighs  in  walking,  and  her  lower  extremities  oede- 
matous,  pitting  decidedly  on  pressure.  The  child  at  this  time  rested 
partly  on  the  thighs  when  she  stood  erect,  and  she  could  frequently  feel 
the  foetal  movements  impressed  on  their  anterior  face,  both  in  walking 
and  sitting,  but  particularly  the  latter.  Gradually,  her  urinary  difficulty 
decreased  as  pregnancy  advanced,  the  secretion  becoming  more  abundant, 
and  at  last  passing  readily. 

Motion  ceased  in  the  foetus  on  January  10th,  1878,  when  it  must  have 
been  within  a  week  or  two  of  its  full  maturity.  Mrs.  O.  now  began  to 
diminish  in  size  and  improve  in  health,  getting  a  better  appetite  and  a 
good  digestion.  Her  menses  made  their  appearance  about  the  first  of  Feb- 
ruary, and  were  preceded  by  intermittent  pains  like  those  of  true  labour, 
deceiving  her  medical  attendant  into  a  belief  that  she  would  shortly  be 
delivered.  The  flow  continued  six  weeks,  and  was  at  times  very  abundant, 
since  which  she  has  been  regular,  the  last  period  closing  on  May  15th, 
three  days  before  the  operation. 

This  is  certainly  a  remarkably  connected  record,  especially  shown  in  its 
symptomatic  succession ;  and  had  we  not  made  the  examination  of  the 
patient  personally,  we  might  have  supposed  that  she  had  in  some  degree 
been  prompted  to  frame  her  statement  of  sensations  ;  but  such  was  not 
the  case.    A  remarkably  good  memory,  closeness  of  observation,  and  a 


326 


Laparotomy  in  a  Case  of  Extra-uterine  Foatation. 


[Oct. 


delicate  sense  of  localization  in  pain  and  sensations,  with  good  common 
sense,  have  enabled  her  to  relate  and  explain  her  own  feelings  intelligibly. 

Condition  before  the  Operation  Mrs.  O.  is  of  medium  height,  rather 

stout,  weighing  ordinarily  136  pounds,  has  a  good  colour,  a  healthy  look, 
and  a  clean  tongue,  but,  at  the  same  time,  an  anxious  expression  of  coun- 
tenance, and  a  pulse  of  105.  She  has  at  times  sudden  attacks  of  vomiting, 
almost  without  warning,  and  says  that  her  condition  is  a  constant  source 
of  disquietude,  night  and  day.  Her  abdomen  is  full  and  still  somewhat 
pendulous,  but  much  less  than  formerly,  and  measures,  when  erect,  35 
inches  in  circumference.  Percussion  and  palpation  show  that  but  little  of 
the  fluid  which  once  so  largely  distended  the  abdomen  remains,  the  excess 
having  been  removed  by  absorption. 

The  foetus  can  be  readily  distinguished,  lying  on  its  right  side,  with  its 
occiput  presenting  to  the  left  groin,  its  spine  to  the  pubes,  and  nates  to  the 
right  of  the  linea  alba ;  in  fact,  it  rests  outside  of  the  pelvis,  across  the 
abdomen,  and  is  sustained  by  the  abdominal  parietes. 

When  upon  her  back,  the  abdomen  has  a  high  narrow  convexity, 
depressed  at  the  umbilicus,  the  centre  of  the  protuberance  being  composed 
of  an  adipose  cake,  about  an  inch  and  a  half  thick  and  ten  inches  across, 
under  the  lower  segment  of  which  lies  concealed  the  dead  foetus.  There 
is  no  pain  or  sensitiveness  in  the  abdomen,  and  the  patient,  when  erect, 
can  readily  lift  the  foetus,  by  placing  her  left  hand  under  its  head,  and 
right,  beneath  the  breech. 

We  should  have  been  glad  to  know  positively  that  this  foetus  was  encysted, 
and  still  more,  that  the  cyst  had  adhered  to  the  abdominal  walls  ;  but  we 
are  not  aware  of  any  method  by  which  either  can  be  safely  and  conclu- 
sively determined.  The  liistory  of  the  case  indicated  that  we  should  in  all 
probability  find  a  partial  or  complete  sac,  the  product,  in  a  measure,  of 
inflammatory  action,  and  the  development  of  the  foetus  made  it  probable 
that  this  cyst  was  not  adherent  in  front.  But  this  was  only  conjectural, 
although  it  proved  to  be  correct.  I  know  that  Dr.  Theodore  Keller,  of 
Strasbourg,  in  his  thesis,  Des  Grossesses  Extra-uterines,  published  in 
1872,  recommends  that  delay  should,  if  possible,  be  made  until  adhesions 
shall  have  been  formed  between  the  cyst  and  the  abdominal  walls ;  but  he 
fails  to  show  how  we  are  to  know  that  there  is  either  a  cyst  or  adhesions. 

The  fact  is,  that  each  case  must  stand  upon  its  own  peculiarities,  and 
the  prognosis  be  made  accordingly.  The  diagnosis  being  established,  much 
will  depend  upon  the  health  of  the  woman,  and  the  variety  of  extra-ute- 
rine pregnancy  to  be  operated  upon.  In  the  case  before  us  we  had  reasons 
for  feeling  hopeful  from  the  first,  and  it  will  be  seen  by  the  result  that  the 
prognosis  was  well  founded. 

It  might  be  thought  questionable  whether  a  rupture  of  a  Fallopian  foetal 

cyst  could  take  place  without  death  from  hemorrhage  as  early  as  the  tenth 

week,  but  for  the  autopsy  made  in  a  similar  case  by  Prof.  K.  von  Braun, 

of  Vienna,  in  December,  1871. 

The  woman  in  question  had  no  severe  attack  of  pain  at  any  time.  She  had  a 
slight  pain  in  the  third  month,  followed  by  emaciation  and  failing  health,  but  was 
always  able  to  keep  about,  although  much  in  hospitals  as  a  patient.    When  Dr. 


1878.] 


Laparotomy  in  a  Case  of  Extra-uterine  Fcetation. 


327 


Braun  saw  her  in  November,  1871,  her  pregnancy  had  nearly  reached  maturity, 
ami  he  proposed  removing  the  foetus ;  but  pain  and  fever  set  in,  and  she  died 
after  a  sickness  of  three  days.  In  five  minutes  after  her  death,  laparotomy  was 
performed,  and  a  living  foetus,  weighing  eight  pounds,  removed,  which  died  in 
ten  minutes.  An  autopsy  showed  distinctly  that  the  pregnancy  had  been  origin- 
ally tubal,  for  in  the  right  Fallopian  conduit  was  the  cyst,  still  containing  the  pla- 
centa, attached  to  the  severed  cord,  and  bearing  evidence  of  the  fact  that  rupture 
had  taken  place  through  a  thin  portion  of  the  cyst-wall,  where  it  would  be 
attended  with  but  little  hemorrhage.  There  was  no  secondary  cyst  formed,  the 
place  of  it  being  partly  supplied  by  pseudomembranous  deposits  around  the 
position  of  the  foetus.  There  had  never  been  any  marked  evidence  of  either 
rupture  or  acute  peritonitis,  as  in  the  case  of  Mrs.  O.  The  right  ovary  in  Dr. 
Braun' s  case  was  about  one-half  the  size  of  the  left,  probably  from  its  blood- 
supply  being  diverted  to  the  cyst  and  placenta.1 

The  first  suspicious  circumstance  in  Mrs.  O.'s  pregnancy  was  the  fact 
that  she  had  remained  unfruitful  so  long  after  marriage,  a  condition  not 
uncommon  in  women  having  a  primiparous  extra-uterine  conception.  Al- 
though primiparai  have  in  some  instances  died  of  Fallopian  pregnancy 
within  a  few  months  after  marriage,  such  immediate  conceptions  are  rare, 
as  it  is  also  in  multiparae,  to  have  a  misplaced  pregnancy,  without  a  longer 
than  usual  interval  having  elapsed  since  the  immediately  preceding  birth. 
This  is  accounted  for  by  the  fact  that  an  abnormal  arrangement  of  the 
tube  in  the  primipara,  and  an  inflammatory  derangement  of  it  in  the  mul- 
tipara, are  often  discovered  in  women  who  have  been  the  subjects  of  extra- 
uterine pregnancies,  and  are  believed  to  have  acted  as  the  producing 
cause. 

Hie  origin  of  pelvic  or  tubal  colic  has  never  been  unquestionably  deter- 
mined, although  it  has  been  thought  to  arise  from  the  giving  way  of  some 
of  the  fibres  of  the  distending  cyst,  especially  as  it  generally  follows  some 
muscular  motion  by  which  abdominal  pressure  is  increased.2  It  is  an  im- 
portant feature  in  the  clinical  history  of  a  case,  especially  when  connected 
with  signs  of  pregnancy,  and  particularly  where  the  feeling  of  foetal  motion 
is  claimed.  The  clinical  history  of  a  case  should  always  be  taken  from 
the  patient  before  any  physical  exploration  has  been  made,  or  we  may  be 
led  into  error,  when  it  would  otherwise  have  been  almost  impossible.  We 
are  not  to  stimulate  a  fertile  imagination,  or  guide  the  patient  into  making 
erroneous  statements  by  leading  questions;  but  to  let  her  tell  her  own 
story,  keeping  her  to  the  order  in  which  events  have  occurred.  In  one 
instance  in  this  city,  a  prominent  surgeon  was  misled  into  believing  that 
a  patient  had  a  malignant  tumour,  until  an  abscess  opened,  through  the 
orifice  of  which  he  felt  bone  in  probing,  and  thus  discovered  his  mistake. 
He  then  found,  by  questioning  the  woman,  that  she  .  had  had  a  train  of 

1  London  Med.  Times,  Sept.  1874,  p.  347,  from  Wiener  Med.  Woch.,  Aug.  8,  1874. 

3  In  a  report  of  a  case  read  before  the  King's  County  Medical  Society,  N.  Y.,  by 
Dr.  C.  H.  Giberson,  on  May  21, 1878,  he  attributes  the  paroxysms  to  hemorrhage  be- 
neath the  outer  investing  layer  of  the  cyst,  and  claims  to  have  established'  the  fact 
by  the  post-mortem  appearances. — Proceedings  Med.  Soc.  County  of  Kings,  June, 
1878,  p.  129. 


328 


Laparotomy  in  a  Case  of  Extra-uterine  Foetation. 


[Oct. 


symptoms  clearly  indicative  of  extra-uterine  pregnancy.  Laparotomy 
confirmed  her  statement,  and  restored  her  to  health. 

The  most  critical  period  in  the  life  of  a  woman  who  has  escaped  death 
by  rupture  of  an  extra-uterine  cyst  until  the  foetus  has  neared  maturity, 
is  that  of  maturity  itself;  when  a  species  of  false  labour  sets  in,  often 
ending  fatally  in  a  variety  of  ways.  If  this  period  has  been  passed  in 
safety,  the  woman  may  escape  death  a  number  of  years,  but  her  life  and 
health  are  never  secure  while  the  foetus  remains  in  the  abdomen,  and  for 
this  reason  there  is  a  growing  disposition  on  the  part  of  accoucheurs  to 
advise  their  early  removal ;  a  procedure  that  recent  experience  teaches  us 
is  less  hazardous  than  delay.  The  very  large  proportion  of  women  saved 
by  laparotomy,  after  the  formation  and  bursting  of  an  abscess,  generally 
near  the  umbilicus,  has  been  used  as  a'very  specious  argument  in  favour 
of  delay  ;  but  we  are  learning  wisdom  by  experience,  and  find  that  too 
many  fall  victims  to  their  condition  before  an  abscess  forms,  or  points  ;  or 
it  points  into  the  rectum,  colon,  bladder,  or  some  inaccessible  place,  and 
results  fatally. 

Had  Mrs.  O.  presented  herself  in  the  first  week  of  January,  it  would 
have  been  possible  to  have  saved  her  child  by  the  primary  operation,  so 
strongly  advocated  by  Keller,  of  Strasbourg,  before  quoted,  who  claims  in 
his  thesis,  that  the  operation  saved  lour  women  and  seven  children,  out  of 
nine  cases  ;  but  the  increased  risk  to  the  former  would  have  made  it  of 
more  questionable  expediency  than  the  secondary.  The  bold  and  success- 
ful operation  of  Mr.  Jessop  of  Leeds,1  England,  in  1875,  on  a  woman 
whose  health  was  failing,  and  life  in  danger,  will  no  doubt  lead  others  to 
make  the  same  attempt ;  and  it  is  possible  that  under  improved  surgical 
management,  future  statistics  may  show  a  more  inviting  record  than  the 
past;  but  at  present,  this  operation,  according  to  history,  appears  to  pro- 
mise much  more  for  the  foetus  than  the  mother.  Parry2  reports  nine 
operations  where  the  child  was  viable,  with  a  saving  of  two  women  and 
eight  living  children. 

In  view  of  the  condition  of  Mrs.  O.  in  January,  it  is  very  questionable 
whether  we  would  have  advised  an  operation,  as  we  did  unhesitatingly  in 
May.  She  was  then  very  much  distended  with  fluid,  her  lower  extremi- 
ties were  cedmatous,  and  her  general  health  by  no  means  as  good  as  it  was 
four  months  later.  There  was  great  risk  to  be  run  during  the  false  labour 
that  was  soon  to  take  place,  but  this  could  hardly  be  equalled  to  the  still 
greater  one,  to  be  incurred  by  a  primary  operation.  It  is  therefore  not  to 
be  regretted,  that  the  question  of  operating  was  not  presented  at  the  time 
specified,  but  came  up  at  a  more  favourable  period,  perhaps  the  most  so 
that  could  have  been  chosen. 

The  changes  that  take  place  in  the  placenta,  and  its  vascular  connec- 

1  Trans.  Obstet.  Soc.  London,  1876,  p.  261. 
a  Extra-Uterine  Pregnancy,  1876,  pp.  229-30. 


1878.]        Laparotomy  in  a  Case  of  Extra-uterine  F  ©station.  329 


tions,  and  the  greatly  diminished  vascularity  of  the  cyst,  especially  when 
not  adherent  to  contiguous  viscera  and  the  abdominal  walls,  are  no  doubt 
the  chief  reasons  why  the  operation  is  less  dangerous  after  the  death  of 
the  foetus.  There  being  no  sac  in  the  Jessop  case  made  it  more  favourable 
in  respect  to  danger  from  hemorrhage  ;  but  a  well-formed  cyst,  adherent 
to  the  abdominal  parietes,  is  of  great  advantage  in  preventing  peritonitis, 
as  the  paritoneal  cavity  is  not  opened. 

It  lias  long  been,  and  is  still  to  some  degree,  an  unsettled  question, 
whether  a  foetus  developed  in  the  abdominal  cavity  should  be  removed 
during  its  life,  within  a  limited  period  after  death,  or  not  until  there  are 
indications  that  an  abscess  is  about  to  point,  or  has  formed  an  opening, 
through  the  abdomen,  vagina,  or  rectum.  The  old  method  of  procedure 
was  based  entirely  upon  the  efforts  of  nature  to  discharge  the  foetus  ;  and 
the  operator  simply  opened  the  abscess,  or  perhaps  enlarged  an  already 
formed  fistula,  so  that  the  foetus  might  be  removed  and  the  placenta  sub- 
sequently discharged,  if  it  could  not  be  distinguished  at  the  time. 

The  first  operation  of  the  second  type  mentioned,  performed  in  this 
country,  appears,  as  far  as  I  have  been  able  to  ascertain,  to  have  been  that 
of  Dr.  Charles  McKnight,  of  New  York,  which  was  reported  after  his 
death,  to  Dr.  J.  C.  Lettsom,  of  London,  in  1795,  by  the  late  Dr.  James 
Mease  of  Philadelphia.  As  Dr.  Mease  graduated  in  1792,  was  present  at 
the  operation,  and  reported  the  case  after  the  death  of  Dr.  McKnight,  the 
woman  must  have  been  operated  upon  at  some  time  between  1792  and 
1795,  the  date  not  having  been  given.  As  the  case  of  Dr.  McKnight  is 
one  of  much  historical  interest,  I  will  give  the  prominent  features  of  it. 

The  woman  became  pregnant  twenty-two  months  before  the  operation,  and 
presented  the  common  symptoms  of  this  condition  during  gestation.  Labour  set 
in  at  the  end  of  nine  months,  but  no  child  presented,  and  in  time  the  pain  ceased, 
but  there  was  no  diminution  in  the  patient' s  size.1  Her  health  was  good  but  mind 
uneasy,  and  she  went  to  New  York  for  advice.  The  physicians  consulted,  agreed 
as  to  her  condition,2  "but  differed  respecting  the  treatment,  whether  the  opera- 
tion should  be  immediately  performed ;  or  as  the  woman  enjoyed  good  health, 
and  as  it  was  impossible  to  ascertain  the  parts  to  which  the  placenta  adhered,  or 
which  it  might  be  necessary  to  injure,  in  the  complete  extirpation  of  the  foetus, 
that  the  operation  should  be  deferred  until  something  like  an  external  imposfhu- 
mation  should  appear,  that  nature  should  thus  point  out  the  place  and  manner  in 
which  extraction  should  be  performed." 

Dr.  McKnight,  who  was  evidently  a  believer  in  surgical  progress,  advised  an 
immediate  operation,  "before  the  woman's  health  should  become  injured,  and 
the  contiguous  parts  suffer  from  compression  and  putrefaction."  Dr.  Mease  re- 
marks :  ' '  the  event  has  proved  that  he  was  right ;  and  I  confess,  from  the  obser- 
vation I  made  during  the  operation,  that  this  reasoning  and  practice  will  always 
be  found  so." 

The  abdominal  tumour  lay  chiefly  to  the  left  side  ;  the  foetal  head  could  be  felt 
in  the  left  groin,  and  what  was  presumed  to  be  a  knee,  above  and  to  the  right  of 
the  umbilicus.  Dr.  McKnight  commenced  his  incision  "on  the  left  side,  some- 
what above  the  navel,  and  a  little  beyond  the  junction  of  the  rectus  and  oblique 

1  This  is  very  questionable,  in  view  of  tlie  fact  that  the  foetal  head  and  knee  could 
he  felt,  and  that  shrinkage  is  generally  regarded  as  universal  in  these  cases. 
3  Memoirs  of  Med.  Soc.  London,  vol.  iv.  1795,  p.  343. 


330 


Laparotomy  in  a  Case  of  Extra-uterine  Feetation.  [Oct. 


muscles,  which  he  continued  to  the  pubes."  The  foetus  proved  to  be  of  large  size, 
and  the  bones  of  the  head  were  removed  to  lessen  its  bulk  ;  it  was  then  extracted, 
but  slipped  and  fell,  so  as  to  rupture  the  cord.  This  accident  proved  all-import- 
ant to  the  woman,  as  the  operator  failed  to  find  the  placenta  after  a  diligent  seareh. 
and  it  had  to  remain  intact.  The  fuetus,  according  to  Dr.  Mease,  was  contained 
in  a  closely  adherent  cyst,  and  the  peritoneal  cavity  was  therefore  not  opened. 
The  discharge  from  the  wound  was  abundant  and  offensive,  and  greatly  reduced 
the  strength  of  the  patient ;  but  she  ultimately  made  a  good  recovery. 

What  to  do  with  the  placenta,1  was  for  years  the  crucial  question  in  this 
operation.  Mr.  William  Turnbull2  was  probably  the  first  to  recommend 
that  it  should  remain  intact,  as  we  learn  by  reading  his  report  of  an 
autopsy  of  a  lady,  who  died  from  the  effects  of  a  ventral  pregnancy  ;  which 
was  presented  to  the  Medical  Society  of  London,  January  10th,  1791.  He 
says  :  "  My  firm  opinion  is,  that  the  separation  and  expulsion  of  the  pla- 
centa should  always  be  left  to  nature,  for  the  extraction  will  be  generally 
fatal  from  the  hemorrhagy  following  it."3  Dr.  Mease,  in  his  letter  to  Dr. 
Lettsom,  contends  for  the  same  non-interference,  but  with  more  practical 
weight,  because  his  opinion  was  backed  by  the  successful  issue  of  an  actual 
trial  of  the  method  proposed  ;  while  that  of  Mr.  Turnbull  was  simply 
based  upon  the  danger  of  removal,  without  any  evidence  that  the  plan 
would  not  be  fatal  to  the  patient.  Unfortunately  for  the  benefit  of  human- 
ity, these  views  were  for  a  long  period  lost  sight  of,  and  we  find  in  after 
years,  strong  objections  made  to  the  operation,  on  the  ground  of  the  sup- 
posed necessity  that  existed  for  removing  the  placenta,  and  the  danger  of 
hemorrhage  and  death  from  so  doing.  Thus  we  find  in  BlundelPs  work 
on  Obstetrics,  in  1840,  page  480,  "On  the  whole,  however,  considering 
the  danger  of  the  incisions,  and  the  risk  of  a  fatal  bleeding  internally, 
when  the  extra-uterine  placenta  is  taken  away,  abdominal  incision  seems 
to  promise  very  little  success." 

M.  Chailly,  1844,  also  speaks  of  the  extraction  of  the  placenta  as  very 
difficult  and  dangerous,  and  recommends  that  the  operation  should  be  per- 
formed only  where  the  woman  is  in  imminent  danger,  or  her  life  rendered 
a  burden  by  suffering.  (Midwifery,  page  79.)  Cazeau  expressed  the 
same  opinion. 

Prof.  Behier,  Paris,  1873,  says,  "  I  would  not  venture  to  propose  it 
(laparotomy)  notwithstanding  the  presence  of  the  products  of  abnormal 
gestation,  for  a  healthy  looking  woman  who  has  probably  before  her,  ten, 
fifteen,  thirty,  and  even  fifty  years  of  tolerable  existence." — (  Gaz.  Heb- 
dom.  36,  1873.) 

I  could  multiply  opinions  for  and  against  the  operation,  both  in  the 
primary  and  secondary  conditions  of  abdominal  pregnancy,  i.  e.,  where 
the  foetus  is  living,  or  has  died,  but  will  refer  the  curious  to  the  work  of 
Dr.  John  S.  Parry,  on  Extra-uterine  Pregnancy  ;  what  we  have  to  deal 

1  See  discussion  in  Trans.  Obstet.  Soc.  London,  Nov.  6th,  1872,  vol.  xiv.  p.  318, 1873. 
3  Memoirs  Med.  Soc.  London,  vol.  iii.  p.  211. 
3  Op.  cit.,  vol.  iv.,  1795,  p.  342. 


1878.]        Laparotomy  in  a  Case  of  Extra-uterine  Fcetation.  331 

with,  being  not  so  much  the  imperfect  records  of  cases  operated  on,  as  the 
histories  of  those,  who  either  declined  the  operation,  or  iii  whom  it  was 
postponed,  that  suppuration  and  pointing  might  take  place.  It  is  very  well 
to  compare  the  relative  mortality  of  cases  operated  upon,  (1)  during  the 
life  of  the  foetus  ;  (2)  after  it  has  been  dead  a  short  time,  and  before  the 
health  of  the  woman  has  become  impaired ;  (3)  at  a  later  period  when 
constitutional  disturbance  makes  it  imperative  ;  (4)  and  still  more  remote, 
when  an  abscess  has  formed  and  pointed ;  but  what  interests  us  is,  to 
know  how  these  postponed  cases  compare  in  results  with  those  that  have 
been  operated  upon  before  the  health  of  the  woman  has  failed.  "We  read 
of  spontaneous  cures ;  of  operations  performed  years  after  the  death  of 
the  foetus,  when  it  has  become  decomposed  and  an  abscess  formed  ;  but 
what  is  said  of  the  number  who  wait  patiently  for  relief  from  the  operations 
of  nature,  and  never  reach  the  condition  in  which,  according  to  the  opinion 
of  many,  the  operation  is  the  most  safe? 

We  read  of  women  carrying  extra-uterine  children  for  more  than  fifty 
years,  and  dying  of  old  age  ;  but  little  is  said  of  those  wrho  died  before  it 
was  thought  prudent  to  operate  upon  them,  falling  victims  to  rupture, 
convulsions,  fever,  diarrhoea,  peritonitis,  exhaustion,  and  septic  poisoning. 

The  life  of  a  woman  carrying  an  extra-uterine  foetus  is  never  safe  from 
rupture,  sudden  disease  and  death  ;  and  this  is  particularly  the  case  at,  or 
soon  after  the  death  of  the  child,  where  the  same  is  of  mature  growth,  and 
developed  in  the  abdominal  cavity.  When  the  foetus  is  small,  has  ceased 
to  grow,  and  is  contained  in  its  original  cyst,  in  the  Fallopian  tube  or 
ovary,  it  may  be  preserved  for  years  without  perceptibly  impairing  the 
health  of  the  woman.  It  may  remain  almost  unchanged  ;  become  shriv- 
elled like  a  mummy  ;  be  converted  into  a  species  of  adipocere  ;  or  undergo 
a  process  of  calcification.  In  rare  instances,  even  large  encysted  children 
have  been  found  well  preserved  after  some  years.  But  in  cases  of  second- 
ary abdominal  pregnancy,  where  there  is  no  sac,  or  the  same  is  incom- 
plete, as  in  Mrs.  0.,  the  foetus  when  dead  may  at  any  time  decompose  in 
immediate  contact  with  the  intestines,  and  peritonitis  or  septicaemia  result. 

The  diagnosis  of  extra-uterine  pregnancy  being  in  some  cases  very  dif- 
ficult, the  plan  of  tapping  the  cyst  by  aspiration  and  testing  the  fluid,  or 
of  drawing  off  a  large  quantity  until  the  foetus  can  be  defined  by  palpa- 
tion, has  been  adopted ;  but  not  with  very  favourable  results  to  the  patient 
in  many  cases ;  as  this  mode  of  procedure  appears  capable  of  precipitating 
a  fatal  termination,  sometimes  in  a  few  days.  We  think  that  these  tests 
should  be  only  used  in  cases  ready  for  and  willing  to  submit  to  an  opera- 
tion, and  that  it  ought  at  once  to  follow,  if  liquor  amnii  should  be  found. 

The  injection  of  antiseptic  washes  after  an  operation  should  be  very 
cautiously  employed,  as,  in  the  absence  of  a  cyst,  violent  and  rapidly  fatal 
peritonitis  may  be  at  once  lighted  up.  Where  there  is  a  cyst,  there  is 
generally  much  less  danger.    I  know  that  the  use  of  dilute  Condy's  fluid 


332 


Laparotomy  in  a  Case  of  Extra-uterine  Fcetation. 


[Oct. 


and  weak  solutions  of  carbolic  and  salicylic  acids  is  generally  commended, 
and  that  they  are  frequently  employed  with  apparent  benefit ;  but  it  is  well 
to  bear  in  mind  that  they  are  sometimes  as  dangerous  as  the  septicemia 
against  which  they  are  made  use  of;  and  especially  is  this  the  case  with 
the  permanganate  of  potash. 

A  few  years  ago,  Prof.  D.  H.  Agnew,  of  Philadelphia,  removed  a  mature 
foetus,  computed  to  have  weighed  ten  pounds,  from  the  vagina  of  a  patient 
of  Dr.  Ellwood  "Wilson,  by  the  post-uterine  incision.  There  was  no  cvst, 
or  a  very  imperfect  one,  the  placenta  separated  without  hemorrhage,  and 
the  woman  did  well  for  eight  days,  when  it  was  proposed  by  a  consulting 
accoucheur,  to  inject  a  weak  solution  of  permanganate  of  potash  into  the 
pelvis,  through  the  wound.  This  was  done,  causing  at  once  a  violent  pain, 
followed  by  peritonitis,  and  death  in  twenty-four  hours.  But  for  this* 
there  is  every  reason  to  believe  that  the  case  would  have  made  a  good 
recovery,  and  in  an  unusually  short  time,  as  there  was  no  placenta  to  be 
removed  by  decomposition.  It  was  a  very  unfortunate  experiment,  and 
should  teach  a  lesson  of  caution  in  the  future  to  obstetric  surgeons.  Non- 
encysted  post-uterine  pregnancies  may  be  operated  upon  with  success,  even 
to  saving  the  foetus;  but  the  parts  are  so  susceptible  to  peritonitis,  that  the 
less  they  are  interfered  with  in  the  after-treatment  the  better.  I  believe 
that  whenever  possible,  the  abdominal  section  should  be  preferred  to  the 
vaginal,  and  in  this  I  am  sustained  by  some  of  our  most  prominent  sur- 
geons. 

As  there  are  still  many  in  our  profession  who  oppose  such  operations  as 

the  one  reported,  and  adhere  to  the  ancient  waiting  for  imposthumation, 

I  will  introduce  a  few  cases  to  show  what  becomes  of  some  of  those  who 

are  not  operated  upon. 

Case  1. — Dr.  Ramsbotham  mentioned,  in  his  Midwifery,  the  ease  of  a  woman 
who  declined  being  operated  upon  for  the  removal  of  a  mature  foetus,  and  died  in 
a  year,  worn  out  with  diarrhoea  and  low  fever.  The  diagnosis  was  verified  by 
autopsy. 

Case  2. — Dr.  W.  C.  Perkins,  of  Philadelphia,  reports  a  case  in  the  Am.  Journ. 
of  Obstetrics  for  May,  1872,  in  which  Drs.  Goodell  and  Parry  were  called  as  con- 
sultants. A  quantity  of  fluid  drawn  off  in  exploration  proved  to  be  amniotic, 
and  the  foetus  could  be  distinguished  by  abdominal  palpation.  Foetal  death  was 
thought  to  have  taken  place  on  Nov.  29th,  1871,  and  the  per- vagi  nam  puncturing 
was  performed  on  Jan.  15th,  1872.  It  was  proposed  to  remove  the  foetus  by  the 
post-uterine  section,  but  the  woman  and  her  friends  declined.  She  was  apparently 
better  at  the  next  visit  after  the  puncture ;  but  pain  and  fever  soon  set  in,  and 
she  died  of  exhaustion  in  six  days  after  the  examination.  The  foetus  was  dead 
53  days,  and  beginning  to  decompose  ;  and  the  enveloping  cyst  was  not  adherent. 
The  case  was  thought  a  reasonably  fair  one  for  the  operation. 

Case  3  Dr.  Frederick  P.  Henry,  of  Philadelphia,  has  kindly  furnished 

the  notes  of  a  case  from  which  I  extract  the  following : — 

Mrs.  D.,  a  native  of  U.  S.,  24  years  old,  third  pregnancy,  first  and  second 
having  been  premature  ;  troubled  after  first  with  some  uterine  malady,  the  prin- 
cipal symptom  being  constant  leucorrhoea,  for  which  she  had  undergone  medical 
treatment.  Called  in  Dr.  Henry  on  July  29th,  1876,  supposing  herself  to  be  in 
labour  at  full  term.    She  had  menstruated  regularly  until  November,  1875;  felt 


1878.]        Laparotomy  in  a  Case  of  Extra-uterine  Foetation.  333 


tlie  sensation  of  quickening  in  March,  1876  ;  and  had  well-marked  and  frequent 
pains  when  examined,  but  the  doctor  found  the  os  high  up,  undilated  and  rigid, 
although  there  was  some  show  of  blood.  After  several  hours  the  pains  ceased, 
and  did  not  return  until  August  21st,  when  they  were  found  strong  and  frequent, 
and  the  woman  very  restless  and  excitable.  An  examination  revealed  the  same 
condition  of  uterus  as  before,  except  that  the  os  was  slightly  opened  ;  no  present- 
ing part  could  be  felt.  After  waiting  several  hours  with  no  advance,  the  hand 
was  introduced  under  ether,  and  two  fingers  into  the  os,  when  a  soft  body  was  felt, 
giving  the  sensation  of  a  placenta,  but  on  more  complete  exploration  proved  not  to 
be,  as  the  fingers  could  be  carried  to  the  fundus  without  encountering  any  ovum. 
This  condition  was  confirmed  by  Drs.  Elliott  Richardson,  and  Nichols,  who 
were  present ;  and  again  three  days  later  by  Dr.  Goodell.  The  patient  at  this 
time  was  very  weak ;  free  from  labour-pains ;  had  much  abdominal  tenderness, 
and  presented  signs  of  peritonitis.  "It  was  decided  not  to  operate,  on  the 
grounds  of  the  woman's  feebleness,  the  fact  that  the  foetus  was  dead,  and  the 
existence  of  peritonitis.    It  was  thought  more  prudent  to  wait." 

Two  hours  after  Dr.  Goodell' s  examination,  and  this  decision  in  consultation, 
the  patient  bad  a  violent  chill,  followed  by  high  fever,  and  a  pulse  of  140  ;  after 
which  she  had  at  times  frequent  chills;  profuse  sweats;  a  very  irritable  stomach; 
and  was  exceedingly  prostrated;  pulse  and  temperature  running  up  to  137  and 
103T75°.  She  died  on  August  30th,  the  ninth  day  after  the  severe  labour-pains 
set  in;  from  "  septiccemia  due  to  absorption  of  putrid  matter  from  the  decom- 
posing fat  us."  The  foetus  was  a  female,  full  size,  and  computed  to  weigh  more 
than  six  pounds.  As  it  was  thought  to  have  died  on  August  21st,  it  was  only 
dead  nine  days  when  the  death  of  the  mother  took  place;  exploration  by  punc- 
ture had  no  doubt  hastened  the  decomposition  of  the  foetus. 

Case  4  Dr.  Edward  L.  Duer,  of  Philadelphia,  has  also  been  kind 

enough  to  send  the  records  of  an  unpublished  case,  of  which  the  following 
is  a  condensed  abstract : — 

Mrs.  F.,  37,  native  of  Massachusetts,  mother  of  three  children,  and  anticipating 
the  birth  of  a  fourth  in  Oct.  1875.  She  stated  that  in  about  the  third  month  she  had 
had  quite  a  sharp  attack  of  peritonitis,  and  was  under  the  care  of  Dr.  Washing- 
ton L.  Atlee,  but  no  suspicion  of  the  case  was  then  entertained.  It  soon  passed 
off",  and  her  size  increased  without  any  unusual  symptoms.  On  Sept.  18th  Dr. 
Duer  saw  her  in  consequence  of  an  attack  of  uterine  pain  which  lasted  but  a  short 
time,  and  was  accompanied  by  a  slight  show  of  blood ;  found  os  uteri  high  up, 
and  of  remarkably  small  size ;  relieved  attack  by  anodyne  suppositories.  Oct. 
4th  had  another  attack,  relieved  temporarily  in  same  way.  Oct.  15th  severe 
continuous  pain,  with  more  decided  hemorrhage.  Having  a  disabled  hand,  called 
in  Dr.  Goodell  to  conduct  the  labor.  Uterus  found  "much  enlarged,  dragged  out 
of  the  pelvis,  and  pushed  forcibly  over  to  the  left  side,  whilst  the  enlarged  os  and 
cervix  were  presenting  behind  the  pubes,  and  correspondingly  difficult  to  reach." 
Abdomen  enlarged  obliquely  upward  from  the  left  iliac  region  to  the  lower  border 
of  the  right  lobe  of  the  liver.  At  a  point  a  little  above  and  to  the  right  of  the 
umbilicus  there  was  an  elevation  about  three  inches  in  diameter,  where  the  pre- 
sumed foetal  cyst  seemed  about  to  point,  the  interposing  tissue  appearing  to  be  not 
more  than  half  an  inch  in  thickness.  The  limbs  of  the  child  could  be  here  felt, 
and  the  head  was  thought  to  lie  in  the  left  iliac  fossa. 

After  a  few  hours  of  rest,  Prof.  Ellerslie  Wallace  was  added  to  the  consulta- 
tion ;  fee  )le  motion  was  felt  in  the  foetus  by  the  patient,  and  the  heart  sounds 
could  still  be  distinguished,  but  both  soon  disappeared.  .  "The  general  conviction 
of  the  consultants,  nevertheless,  was  in  favour  of  delay,  with  the  view  of  securing 
a  better  condition  for  operative  interference." 

The  patient  took  a  fair  quantity  of  liquid  food ;  slept  well  under  anodynes  ; 
had  no  marked  peritonitis,  or  great  rise  of  temperature,  but  all  the  time  a  high 
pulse.  "The  temptation  to  operate,  not  in  the  canonical  way,  but  by  incision 
into  the  cyst- like  prominence  at  the  side  of  the  umbilicus,  was  constant  and  great ; 
but  in  accordance  with  what  then  seemed  a  better  judgment,  the  temptation  was 


334 


Laparotomy  in  a  Case  of  Extra-uterine  Fcetation. 


[Oct. 


put  aside  just  too  long."  Consultations  were  held  daily  for  sixteen  days,  but  at 
no  time  could  all  agree  to  take  the  responsibility  of  operating. 

On  the  evening  of  the  last  day  of  the  consultation,  after  having  appeared  much 
better  than  usual,  Mrs.  F.  was  suddenly  seized  with  agonizing  pains,  followed  at 
once  by  a  state  of  collapse,  and  died  in  thirty  minutes.  No  autopsy  was  allowed. 
Dr.  Duer  says:  "My  own  reflection  on  this  case  is  the  regret  of  non-operating; 
in  the  light  of  present  knowledge,  of  enhanced  chances  by  so  doing,  and  the  dan- 
ger of  delay  in  operating,  in  the  hope  that  adhesions  may  form  and  an  abscess 
point,  so  that  the  foetus  may  be  cut  down  upon  and  removed  with  less  risk  of 
peritonitis,  I  believe  our  treatment  would  have  been  far  different,  and  possibly 
have  furnished  us  a  different  result." 

As  Dr.  Duer  says  of  his  case,  the  delay  was  fatal.  In  all  probability 
death  resulted  from  rupture  of  the  cyst-wall,  an  accident  not  uncommon 
at  the  maturity  of  an  abdominal  pregnancy.  It  is  to  be  regretted  that  the 
patient  was  not  examined  post  mortem,  but  in  similar  cases  that  have  been 
the  cyst  was  found  to  have  given  way.  More  progress  has  been  made 
during  the  last  ten  years,  and  especially  the  last  six,  in  enlightening  the 
profession  upon  the  treatment  of  these  cases,  than  in  any  former  period. 
We  are  beginning  to  learn  that  the  cautions  of  the  past  were  in  many  in- 
stances founded  in  error,  and  that  there  is  more  promise  often  in  a  bold 
and  prompt  use  of  the  knife.  Every  failure  by  delay,  and  every  success 
by  an  operation,  has  an  influence  in  converting  those  in  interest  to  the  new 
method  of  treatment.  My  extensive  researches  in  American  Cesarean 
cases  convinced  me  that  theoretically  there  ought  not  to  be  a  very  high 
rate  of  mortality  in  laparotomy  for  the  removal  of  an  extra-uterine  fcetus 
after  death,  at  or  near  maturity ;  and  a  more  direct  investigation  proves 
that  I  was  correct.  It  having  been  satisfactorily  settled  that  the  placenta 
is  not  to  be  touched,  that  the  cyst  is  to  be  stitched  to  the  abdominal  pari- 
etes,  and  that  the  lower  part  of  the  wound  is  to  be  kept  open,  there  is  much 
less  risk  to  be  apprehended  than  formerly  from  the  operation,  provided  the 
condition  of  the  woman  is  reasonably  good  at  the  time  of  its  performance. 
There  is  less  danger  of  peritonitis  and  septicaemia  than  where  the  uterus 
has  been  incised  after  a  long  labour,  and  there  ought  to  be  as  many  re- 
coveries as  in  Cesarean  cases  early  operated  upon,  or  three  saved  to  one* 
lost.  But  even  this  may  not  be  the  limit  of  success,  as  Dr.  Thomas  saved 
all  of  his  cases  in  New  York,  a  much  better  result  than  has  followed  his 
laparo-elytrotomy. 

I  could  multiply  cases  to  prove  the  same  point,  but  the  four  given  are 
enough  to  show  that  to  wait  is  often  to  lose  the  patient.  As  there  is  evi- 
dently much  danger  at  the  maturity  of  the  fcetus,  it  becomes  a  serious 
question  whether  it  would  not  be  safer  to  operate  in  the  eighth  month  than 
to  wait  until  after  the  false  labor  is  over  and  fcetus  dead.  So  many  women 
have  lost  their  lives  in  the  ninth  month,  or  soon  afterward,  that  it  would 
appear  as  if  the  risk  in  operating  should  be  less  than  in  postponing;  but 
this  has  yet  to  be  tested  in  the  future.  One  obstacle  is  the  great  difficulty 
in  diagnosis,  and  the  wrant  of  agreement  in  consultants.  A  woman  may 
cease  to  menstruate  {from  diseased  ovaries) ;  become  enlarged  during 


1878.]        Laparotomy  in  a  Case  of  Extra-uterine  Foetation. 


335 


nine  months  (  from  a  benign  uterine  tumour)  ;  feel  confident  that  she  has 
quickened  (when  there  is  no  feet  us)  ;  have  her  breasts  affected  sympatheti- 
cally (  when  not  pregnant)  ;  and  present  many  of  the  sympathetic  evidences 
of  this  condition,  thus  misleading  her  physician,  who  fears  to  try  the  ute- 
rine sound.  False  labour  may  even  set  in  at  the  end  of  nine  months ;  but 
there  is  no  uterine  hemorrhage  as  in  extra-uterine  pregnancy ;'  and  the 
abdomen  does  not  diminish  in  size  afterward,  by  absorption  of  the  liquor 
amnii,  as  it  almost  invariably  does  where  there  is  a  foetal  cyst.  The  two 
important  tests,  of  labour-pains  with  hemorrhage  and  subsequent  diminu- 
tion of  abdominal  development,  cannot  be  obtained  in  time  to  make  them 
of  any  value  in  &  primary  operation,  and  we  are  forced  to  make  a  diagno- 
sis from  other  evidences.  The  foetal  heart  may  be  heard  distinctly  in  a 
normal  location ;  the  os  uteri  may  feel  as  in  a  uterine  foetation ;  the  uterus 
may  be  lifted  behind  the  pubes;  and  the  enlargement  in  Douglas's  cul-de- 
sac  be  mistaken  for  the  renexed  body  of  the  organ;  and  the  sound  may 
be  arrested  in  the  uterus  at  a  normal  depth  when  but  half  introduced,  and 
yet  the  foetus  be  in  the  abdominal  cavity. 

The  facts  and  errors  enumerated  have  all  been  taken  from  actual  cases, 
many  of  them  in  the  hands  of  celebrated  men;  and  even  an  exploratory 
incision  has  not  revealed  the  true  condition,  as  subsequently  proved  by 
autopsy.  We  are  therefore  to  exercise  the  greatest  possible  precaution 
before  proceeding  to  remove  an  extra-uterine  foetus  during  its  viable 
period. 

The  experience  of  Dr.  T.  Gaillard  Thomas,  of  New  York,  in  extra- 
uterine cases,  is  very  encouraging  to  any  one  who  desires  to  be  upheld  in 
a  decision  to  operate,  rather  than  delay,  and  goes  to  show  that  laparotomy, 
under  careful  management,  may  prove  less  dangerous  than  any  other  plan 
of  treatment.  He  has  had  fourteen  cases  of  extra-uterine  pregnancy,  all 
within  the  last  ten  years.  Nos.  1,  2,  5,  and  13  were  all  early  tubal  cases, 
seen  in  consultation  after  the  cyst  had  ruptured;  and  all  died.  In  No.  13 
the  Doctor  was  very  anxious  to  open  the  abdomen,  and  arrest  the  bleeding 
by  ligation ;  but  his  diagnosis  was  not  concurred  in,  or  his  plan  acquiesced 
in.  The  lady  died  in  sixty  hours,  and  an  autopsy  revealed  the  fact,  that 
the  sac-wall  was  slightly  broken,  by  which  a  small  artery  had  given  way, 

1  Even  the  test  of  hemorrhage  during  gestation,  or  the  false  labour,  would  appear 
not  to  he  infallible.  In  a  case  observed  by  Dr.  William  R.  King  {Richmond  and  Louis- 
ville Med.  Joicrn.,  Sept.  1868),  there  was  no  uterine  discharge,  from  the  cessation  of 
the  menses,  until  their  natural  return,  as  after  a  normal  labour.  Shrinkage  occurred 
and  continued  for  two  years,  when  the  cyst  was  of  the  size  of  a  uterus  at  five  and  a 
half  months,  and  occupied  the  left  side  of  the  abdomen,  where  the  tumor  was  first 
discovered.  At  the  time  of  the  false  labour  the  movement  of  the  foetus  was  strongly 
marked.  The  woman  was  in  good  health  six  years  afterward.  From  some  peculiarity 
there  could  either  have  been  no  decidua,  or  it  was  thrown  off  at  the  regular  menstrual 
period  immediately  following  impregnation,  as  I  once  observed  in  a  tubal  case,  and 
was  overlooked,  this  menstrual  act  being  counted  as  the  last  before  conception. 


336 


Laparotomy  in  a  Case  of  Extra-uterine  Fcetation. 


[Oct. 


causing  death  by  a  slow  hemorrhage.  In  Dr.  Thomas's  opinion,  this 
hemorrhage  could  have  certainly  been  arrested;  and  it  is  much  to  be 
regretted  that  the  operation  was  not  tested  in  so  promising  a  case. 

Nos.  3  and  4  were  early  cases  which  he  treated  by  puncture  with  a 
small  trocar;  the  first  was  followed  by  pain  in  twelve  hours,  and  death 
resulted  with  symptoms  of  rupture.  The  second  was  in  the  third  month, 
and  gave  great  relief;  septicaemia  developed  on  tenth  day,  and  death  re- 
sulted. 

Nos.  6,  7,  and  8  were  all  early,  and  left  to  nature ;  No.  6  passed  the 
foetus  by  the  rectum,  as  did  also  No.  8,  and  both  recovered.  No.  7  died 
of  septicaemia;  one  of  the  three,  in  consultation,  opposing  interference. 

No.  9  was  a  left  tubal  pregnancy  of  three  months,  operated  on  by  the 
post-uterine  incision,  with  a  galvano-cautery  knife.    The  lady  recovered. 

No.  10  was  an  abdominal  pregnancy  of  thirteen  months'  duration,  with 
a  full-grown  foetus.    Operated  upon  by  laparotomy  ;  recovered. 

No.  11,  the  same;  twenty-two  months'  duration;  foetus  eight  pounds; 
the  same  operation  and  result. 

No.  12,  the  same;  seventeen  months' duration  ;  foetus  eight  pounds; 
same  operation  and  result. 

No.  14  was  a  left  tubal  pregnancy  of  three  months;  galvanic  battery 
twice  applied.  Labour-pains  severe  after  second  application,  and  foetus  ex- 
pelled into  uterus  and  out  by  the  os.  Patient  recovered.  Sound  measure- 
ment before  treatment  3^  inches.  Uterus  found  normal  in  shape  after 
recovery.  Case  reported  by  Dr.  Charles  McBurney  in  N.  T.  Med.  Journ., 
March,  1878,  p.  273. 

Thus  we  have  four  operations  for  removal  of  foetus,  all  successful.  Two 
punctures,  both  fatal;  three  left  to  nature,  with  one  fatal,  all  pointing  into 
rectum  ;  four  early  tubal  ruptures,  all  fatal ;  and  one  tubal,  discharging 
by  the  uterine  cavity,  with  recovery.  It  certainly  looks  as  if  it  was  safer 
to  remove  the  child  by  the  abdominal  section  than  to  try  any  other  plan 
of  management.1 

*Y\  hen  the  Dieulafoy  aspirateur  was  first  introduced  to  the  profession,  it 
was  thought  that  tapping  the  cyst  with  it,  so  as  to  destroy  the  foetus  if  in 
the  early  months,  or  lessen  the  danger  of  rupture  by  tension,  if  already 
dead,  might  be  a  valuable  method  of  treatment ;  but  aspiration  has  been 
found  very  unsafe,  even  when  performed  with  a  very  small  tube.  It  has 
been  proposed  to  inject  solution  of  morphia,  to  poison  the  foetus;  and  to 
prevent  septic  poisoning,  after  removing  the  fluid,  by  injecting  antiseptics 
into  the  cyst.  The  first  of  these  experiments  is  claimed  to  have  succeeded 
in  the  hands  of  Prof.  Friedrich  (  Yir chow's  Archiv,  xxix.  3,  4),  who 
made  four  injections,  and  claims  to  have  allayed  the  pain,  and  arrested 

1  I  have  purposely  given  a  very  condensed  record  of  Dr.  Thomas's  cases,  as  he  has 
promised  to  present  them  in  full,  as  the  basis  of  an  article  to  be  shortly  published  ; 
some  have  already  appeared,  as  9,  10,  and  li. 


1878.]        Laparotomy  in  a  Case  of  Extra-uterine  Foetation.  337 

the  growth  of  the  foetus.  He  also  says  that  the  foetus  was  absorbed,  which 
I  hardly  believe  possible  on  physiological  grounds. 

In  performing  the  operation  upon  Mrs.  0.,  Dr.  Atlee  had  but  one  object 
in  view,  the  best  interest  of  the  patient;  to  which  he  made  all  matters  of 
personal  ambition  or  scientific  inquiry  subservient.  He  first  became  con- 
vinced that  it  was  safer  to  operate,  under  the  circumstances,  than  post- 
pone ;  and  then  entered  upon  the  operation  with  very  sanguine  hopes  of 
success,  to  accomplish  which  he  determined  to  try  no  experiments,  and  to 
avoid  everything  in  the  way  of  handling  that  might  endanger  the  case. 
He  was,  therefore,  in  no  hurry  in  cutting  into  the  abdomen;  did  not 
sponge  out  the  cyst,  but  simply  absorbed  the  fluid  as  it  escaped,  and  did 
not  introduce  his  hand  into  the  abdomen,  either  in  removing  the  foetus,  or 
to  ascertain  the  attachments  of  the  placenta.  The  opening  of  the  cyst 
required  minutes;  removing  fluid  and  foetus,  12J;  and  dressing  the 
wound,  15  minutes;  in  all,  33  minutes  from  commencement  to  putting  the 
,svoman  in  bed.  When  I  cut  the  funis  it  resisted  the  scissors  like  a  sprout 
of  asparagus,  and  the  cut  surface  presented  no  trace  of  vascular  structure. 
The  cord  was  of  a  dead-green  colour,  and  had  undergone  a  species  of 
carnification,  which  had,  probably,  also  affected  the  placenta.  The  in- 
cision in  the  linea  alba  started  but  three  arterioles  not  larger  than  bristles, 
and  the  blood  lost  was  unusually  trifling. 

Soon  after  the  operation  I  counted  her  pulse  at  98 ;  and  it  is  said  to 
have  been  as  low  as  84  in  the  afternoon ;  but  I  have  never  found  it  as 
slow  at  any  time  since.  The  day  before  the  post-placental  abscess  burst 
into  the  vagina  I  counted  it  118,  which,  I  believe,  was  the  highest  point 
reached.  On  the  thirty-eighth  day  I  found  it  96  ;  and  on  the  fifty-first 
day  still  as  high  as  90.  She  had  at  this  date  (July  8)  no  pain  on  defeca- 
tion or  urination,  no  abdominal  tenderness  under  pressure,  and  her  tongue 
was  perfectly  natural.  There  was  still  a  small  opening  in  the  abdominal 
wound,  through  which  there  was  discharged  daily  about  a  tablespoonful  of 
thin,  sero-purulent  fluid ;  but  no  tissue-shreds  had  passed  for  more  than 
two  weeks.  She  menstruated  naturally,  as  to  duration  and  amount,  on 
July  1,  et  seq.;  and  said  that  she  felt  well,  and  had  regained  the  flesh  lost 
by  the  operation  and  sickness.  There  was  nothing  to  indicate  any  trou- 
ble in  the  future,  and  the  changed  character  of  the  discharge  gave  hope  of 
an  early  closure  of  the  fistula. 

There  has  been  a  growing  disposition  on  the  part  of  several  leading 
accoucheurs  in  this  city,  manifested  for  a  few  years  past,  to  depart  from 
the  conservative  method  in  the  management  of  abdominal  pregnancies, 
and  recommend  the  early  removal  of  the  foetus  by  incision  through  the 
vagina  or  abdomen;  reasoning  from  analogy  that  this  should  not  be  so 
fatal  a  method  of  relief  as  has  generally  been  believed.  In  two  instances 
the  foetus  was  removed  by  vaginal  incision,  but  both  women  died;  one 
case  being  that  of  Dr.  Wilson,  already  mentioned,  and  the  other  an  opera- 
No.  CLII  Oct.  1878.  22 


338         Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  [Oct. 


tion  by  Dr.  Albert  H.  Smith,  with  Paquelin's  thermocautery  knife,  in 
which  he  encountered  the  placenta  in  the  line  of  incision.  The  operation 
by  Dr.  Atlee,  as  far  as  I  have  been  able  to  ascertain,  is  the  first  one  of  its 
kind  that  has  been  performed  in  Philadelphia.  The  dead  foetus  has  been 
removed  after  the  pointing  of  an  abscess,  but  in  no  instance  before  suppu- 
ration had  commenced,  as  in  his  case.  The  fatal  cases  reported  within  a 
few  years  that  it  is  now  thought  might  have  been  saved  by  opening  the 
abdomen  promptly,  will  no  doubt  bear  fruit  in  the  future  in  the  form  of  a 
more  decided  disposition  to  operate,  and  a  greater  hopefulness  in  the  re- 
sult to  the  women.  The  successes  of  Drs.  Thomas,  Jessop,  and  Atlee 
should  certainly  encourage  others  to  follow  their  example. 
713  Locust  Street,  July  30, 1878. 


Article  II. 

Ox  the  Relations  between  Progressive  Ataxy  and  Spasmodic  Spinal 
Paralysis.  By  Julius  Althaus,  M.D.,  M.R.C.P.  Lond.,  Senior  Phy- 
sician to  the  Hospital  for  Epilepsy  and  Paralysis,  Regent's  Park.  London. 

Recent  microscopic  investigations  of  the  anatomical  changes  in  these 
two  diseases  have  shown  that  the  lesion  does  not  originally  affect  the  en- 
tire extent  of  the  several  columns  of  the  spinal  cord,  but  only  a  certain 
portion  thereof.  In  progressive  locomotor  ataxy  the  morbid  process  begins 
in  that  part  of  the  posterior  columns  which  Henle  has  termed  the  "  Keil- 
strang,"  funiculus  caudatus,  and  which  the  French  anatomists  call  the 
"rubans"  or  "  bandelettes  externes  ;"  that  is  to  say,  the  external  portion 
of  the  posterior  column,  wrhich  is  in  close  proximity  to  the  posterior  roots 
of  the  spinal  nerves  ;  while  the  internal  portion  of  the  same,  which  Bur- 
dach  has  called  the  funiculus  gracilis,  but  which  is  now  generally  known 
as  GolPs  column,  is  not  primarily  affected,  but  only  suffers  later  on,  when 
the  disease  spreads  to  the  other  portions  of  the  nervous  matter,  such  as 
the  posterior  roots,  the  posterior  cornua  of  the  gray  matter,  etc.  On  the 
other  hand,  in  spasmodic  spinal  paralysis,  spasmodic  tabes  dorsalis,  or 
lateral  sclerosis  of  the  spinal  cord  (Erb,  Charcot),  the  lesion  attacks  first 
the  posterior  portion  of  the  lateral  columns,  which  Flechsig  has  termed 
the  crossed  pyramidal  column,  and  which  is  composed  of  fibres  derived 
from  the  opposite  cerebral  hemisphere.  This  is  distinct  from  the  lateral 
column  proper,  which  Is  situated  more  anteriorly,  and  the  direct  cerebel- 
lar column,  which  lies  more  to  the  rear.  The  pyramidal  column  is  in 
this  disease  found  studded  writh  wredge-shaped  gray  patches,  reaching  an- 
teriorly as  far  as  the  lateral  column  proper,  exteriorly  as  far  as  the  pia 
mater,  and  interiorly  as  far  as  the  posterior  cornua.  This  peculiarity  in 
the  localization  of  the  disease  distinguishes  it  anatomically  (a)  from 


1878.]     Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis  339 

Tiirck's  degeneration,  or  secondary  lateral  sclerosis  consequent  on  cerebral 
hemorrhage,  in  which  the  patches  are  rounded,  not  wedge-shaped,  and  do 
not  spread  exteriorly  as  far  as  the  pia  mater  ;  and  (5)  from  secondary 
sclerosis  after  myelitis,  hemorrhage  into  the  cord,  etc.,  where  the  gray 
patches  do  not  extend  posteriorly  as  far  as  the  posterior  cornua,  but  where 
a  small  intermediate  layer  of  healthy  white  matter  remains  between  them 
and  the  sclerosed  tissue. 

In  analyzing  the  various  symptoms  which  we  meet  with  in  posterior 
and  lateral  sclerosis,  we  find  that  the  most  important  in  the  former  are 
referable  to  sensory  disturbance  and  want  of  motor  coordination  ;  while 
true  paralysis,  with  muscular  spasms  and  rigidity,  may  be  considered 
characteristic  of  the  latter.  I  will  now  endeavour  to  trace  these  symptoms 
to  morbid  alteration  of  the  normal  functions  of  the  affected  parts,  such  as 
they  are  known  to  us  from  the  present  teaching  of  experimental  physi- 
ology. 

That  sensibility  in  its  various  forms  should  suffer  in  disease  of  the  pos- 
terior columns,  is  only  what  might  be  expected,  inasmuch  as  these  parts 
have  been  experimentally  shown  to  contain  the  chief  paths  for  the  con- 
duction of  the  senses  of  touch,  pressure,  temperature,  and  tickling.  In 
accordance  with  this  we  find  such  symptoms  as  the  following :  a  feeling  of 
constriction  round  the  chest,  abdomen  and  limbs  ;  numbness  and  tingling 
in  the  legs  and  feet ;  a  sensation  in  walking  as  if  the  patient  stepped  on 
bladders  or  cotton  ;  tardy  sensation,  so  that  several  seconds  are  required 
for  appreciating  an  impression  which  has  been  made  ;  loss  of  the  keenness 
of  touch,  so  that  the  patient  is  unable  to  tell  the  nature  of  an  object  which 
is  given  him  to  touch,  without  the  help  of  his  eyes  ;  diminution  or  loss  of 
the  muscular  sense,  so  that,  without  looking,  the- patient  is  not  aware  of 
the  position  of  his  limbs,  or  of  any  changes  which  are  made  in  it  by 
others.  All  these  signs,  and  in  the  later  stages  of  the  disease,,  cutaneous 
anaesthesia,  are  amongst  the  commonest  symptoms  of  ataxy,  and  absent 
only  in  the  most  exceptional  cases. 

A  prominent  symptom  of  tabes  dorsalis  is  a  peculiar  kind  of  pain  which 
darts  through  the  limbs  like  lightning,  occurs  chiefly  at  night,  selects 
mostly  the  lower  extremities,  but  spares  no  part  of  the  body,  is  sometimes 
neuralgic  in  character,  so  that  there  is  a  paroxysm  and  afterwards  an  in- 
terval of  rest,  while  at  other  times  it  is  more  continuous,  and  lasts  in 
various  degrees  of  intensity  for  weeks  and  months.  Now  it  has  been 
shown  that  the  paths  for  the  conduction  of  the  sensation  of  pain  are  not 
situated  in  the  posterior  columns,  but  in  the  central  gray  matter ;  and  as 
the  pain  to  which  I  have  just  alluded,  is  one  of  the  most  constant  earlier 
symptoms  of  posterior  sclerosis,  and  occurs  at  a  period  when  the  central 
gray  matter  is  still  unaffected,  it  must  be  referred  to  irritation  of  the  pos- 
terior roots  in  Henle's  "  Keilstrang,"  where  the  disease  is  located  in 
the  first  instance. 


340         Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  [Oct. 

A  far  greater  difficulty  is  experienced  in  physiologically  explaining  the 
symptom  of  ataxy,  or  want  of  coordination,  which  is  not  only  locomotor, 
as  usually  stated,  i.  e.,  perceptible  in  complex  movements,  but  also  static ; 
that  is  to  say,  that  there  is  a  difficulty  or  impossibility  of  keeping  the  arms 
and  legs,  the  body,  and  in  some  cases  even  certain  muscles  supplied  by 
the  cranial  nerves,  for  any  time  fixed  in  certain  positions.  The  atactic 
patient  has  indeed  not  only  great  difficulty  in  walking,  but  cannot  stand 
erect  with  the  feet  close  together.  Where  the  disease  affects  the  cervical 
cord,  he  finds  it  impossible  to  write,  dress,  play  musical  instruments,  etc., 
and  cannot  well  keep  his  arm  or  hand  stretched  out  in  a  certain  direction. 
This  symptom  of  locomotor  and  static  ataxy  is  a  true  motor  phenomenon, 
and  not  dependent  upon  anaesthesia,  as  was  formerly  believed.  That  such 
is  the  case,  is  shown  by  the  fact  that  the  degree  of  ataxy  is  not  at  all  pro- 
portionate to  the  degree  of  anaesthesia  which  may  be  present,  inasmuch 
as  the  one  is  occasionally  found  slight,  and  the  other  severe,  and  vice 
versa.  Moreover,  complete  anaesthesia  of  the  limbs  may  exist  without 
simultaneous  ataxy,  which  alone  renders  it  evident  that  this  latter  is  noth- 
ing but  a  symptom  of  disordered  motion. 

As  both  locomotor  and  static  ataxy  occur  with  great  regularity  in  dis- 
eases of  the  posterior  columns,  we  would  naturally  draw  the  inference  that 
these  structures  are  the  centres  for  the  coordination  of  complex  move- 
ments ;  yet  Goltz's  experiments  have  shown  unmistakably  that  no  such 
centres  exist,  either  in  the  posterior  columns,  or  anywhere  throughout  the 
entire  extent  of  the  cord  ;  on  the  contrary,  they  are  situated  in  the  brain, 
residing  more  particularly  in  the  corpora  quadrigemina,  the  optic  thalamus, 
and  the  cerebellum.  If  therefore  the  posterior  columns  are  not  actual 
centres,  we  might  at  least  expect  them  to  contain  the  paths  by  which  the 
coordinating  impulses  travel  from  the  brain  to  the  muscles.  But  even 
this  supposition  is  controverted  by  Woroschiloff 's  experiments,  which  tend 
to  show  that,  at  least  in  the  rabbit,  these  paths  are  situated  in  the  middle 
third  of  the  lateral  columns  of  the  cord,  and  do  not  touch  the  posterior 
columns  at  all.  Physiology  and  pathology  seem  therefore  in  such  a  simple 
case  as  this  for  the  present  hopelessly  at  variance  with  each  other ;  and 
we  must  leave  to  future  observations  the  task  of  reconciling  these  ap- 
parently discrepant  phenomena. 

Experimental  destruction  of  the  posterior  columns  in  animals  does  in 
no  way  impair  the  voluntary  motion  of  the  parts  behind  the  lesion  ;  and 
in  accordance  with  this  we  find  that  in  the  first  two  stages  of  sclerosis  of 
these  columns  there  is  no  loss  of  voluntary  power  over  the  muscles,  or 
paralysis.  The  patient  may  be  unable  to  walk  or  to  use  his  limbs  for  any 
useful  purpose,  but  is  still  in  possession  of  motor  power,  so  that  when  he 
is  sitting  or  lying  down,  he  can  move  his  legs,  cross  one  over  the  other, 
etc.,  and  it  is  only  in  the  later  stages  of  the  disease,  when  the  sclerosis 


1878.]     Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  341 


creeps  up  to  other  portions  of  the  spinal  centre,  that  true  paralysis  may 
be  observed. 

The  functions  of  the  lateral  columns  of  the  cord  are  still  to  a  great  ex- 
tent enveloped  in  obscurity.  There  is  diversity  of  opinion  amongst  physi- 
ologists with  regard  to  their  being  concerned  in  the  conduction  of  sensa- 
tions ;  but  it  appears  highly  probable  that  each  lateral  column  contains 
sentient  fibres  for  both  extremities,  and  that  these  fibres  cross  over  from 
one  to  the  other  side  of  the  organ.  Pathological  observation  does  not 
quite  tally  with  these  data,  for  in  a  number  of  cases  of  lateral  sclerosis 
symptoms  in  the  sphere  of  sensibility  are  entirely  wanting,  while  in  some 
we  find  pain,  tingling,  numbness,  a  feeling  of  heat  and  cold  in  the  skin, 
etc. ;  but  even  in  these  latter  cases  the  sensory  disturbance  only  occurs  in 
the  commencement  of  the  disease,  and  is  very  moderate  in  degree.  On 
the  other  hand,  the  lateral  columns  are  generally  acknowledged  to  contain 
the  principal  paths  for  the  voluntary  movements  for  the  extremities,  for 
which,  however,  they  are  associated  throughout  with  the  large  ganglionic 
masses  of  the  gray  anterior  cornua,  and  the  anterior  roots  of  the  spinal 
nerves.  In  accordance  with  this  we  find  that  in  lateral  sclerosis  loss  of 
motive  power  in  the  extremities,  constitutes  one  of  the  principal  symp- 
toms. 

This  loss  of  power  is  at  first  very  slight.  The  patient  feels  weak  in  the 
legs,  and  has  a  difficulty  in  going  up  and  down  stairs  ;  after  walking  a 
short  distance  he  is  greatly  fatigued.  There  is  great  difficulty  in  lifting 
the  feet  from  the  ground  ;  they  are  apt  to  shuffle  along  it,  and  the  soles  of 
the  boots,  by  scraping  the  ground,  are  sooner  worn  out  at  the  toes  than 
formerly.  The  patient  soon  takes  to  sticks  or  crutches.  Coincident  with 
the  loss  of  power  there  is  motor  irritation,  as  shown  by  twitches,  cramps 
and  convulsions,  which  are  apt  to  occur  after  fatigue,  but  often  come  on 
without  any  apparent  exciting  cause,  and  with  considerable  regularity, 
nay,  periodicity,  at  certain  hours  of  the  day.  After  a  time,  the  muscles 
assume  a  degree  of  rigidity,  which  in  its  turn  renders  voluntary  move- 
ments more  difficult,  and  causes  resistance  to  passive  movements.  The 
patient  finds  it  difficult  to  stoop.  The  legs  resist  flexion,  extension  and 
abduction,  and  the  foot  assumes  the  position  of  varo-equinus.  This  state 
of  things  induced  Seguin  to  describe  the  complaint  as  "  tetanoid  para- 
plegia." 

In  consequence  of  these  differences  in  the  pathological  condition  of  the 
lower  extremities,  the  gait  of  the  patient  affected  with  ataxy  forms  a  com- 
plete contrast  to  that  which  is  seen  in  one  suffering  from  lateral  sclerosis. 
The  ataxic  patient  uses  his  eyes  as  crutches,  and  is  constantly  looking  at 
his  feet  in  order  to  guide  their  movements.  He  walks  in  a  jerky  and  ir- 
regular manner,  puts  his  feet  down  with  force,  throws  the  toes  heavily 
forwards  and  outwards,  staggers  in  turning  round,  and  has  to  manoeuvre 
considerably  with  his  arms  in  order  to  prevent  himself  from  falling.  On 


342 


Altiiaus,  Ataxy  and  Spasmodic  Spinal  Paralysis. 


[Oct. 


closing  the  eyes,  or  in  the  dark,  he  is  particularly  unsteady,  and  liable  to 
fall.  The  patient  with  lateral  sclerosis,  on  the  other  hand,  seems  to  be, 
as  it  were,  fixed  in  a  vice.  While  he  has  no  difficulty  in  standing,  the 
legs  appear  so  stiff  that  he  is  almost  unable  to  get  the  feet  from  the 
ground  ;  he  walks  on  tiptoe  ;  the  whole  body  seems  to  join  in  a  spasmodic 
effort,  and  is  thrown  forward,  in  order  to  aid  the  action  of  the  legs.  There 
is  tendency  to  fall  forwards  ;  yet  the  help  of  the  eyes  is  not  sought  in 
walking,  and  light  or  dark  makes  no  difference  in  it. 

The  faculty  of  reflex  action  has  been  shown  to  reside  in  the  ganglionic 
cells  of  the  central  gray  matter  of  the  cord,  where  sentient  impressions  are 
conveyed  from  the  posterior  roots  of  the  spinal  nerves  to  motor  paths  in 
the  anterior  roots.  Destruction  of  the  gray  matter  annihilates  reflex  ac- 
tion. Thus  we  find  that  in  anterior  polio-myelitis,  where  the  anterior 
cornua  are  disorganized  by  inflammation,  no  reflex  movements  can  be 
elicited,  although  tickling  of  the  soles  is  distinctly  perceived,  and  sensibil- 
ity altogether  normal.  Neither  the  posterior  nor  the  lateral  columns  con- 
tain any  centres  for  this  faculty,  and  coincidently  with  this  we  find  that 
in  posterior  as  well  as  lateral  sclerosis  the  reflex  function  of  the  skin  and 
mucous  membranes  is  in  a  general  way  preserved.  A  singular  and  im- 
portant feature  of  the  two  diseases  which  we  are  now  considering  is,  how- 
ever, the  behaviour  of  tendinous  reflexion,  which  appears  to  present  a 
marked  contrast  in  them.  Westphal  and  Erb  have  shown  that  reflex 
movements  may  be  elicited,  independently  of  cutaneous  stimulation,  by 
giving  a  tap  or  blow  with  the  fingers  or  a  hammer  on  certain  tendons, 
such  as  that  of  the  rectus  femoris,  the  tendon  Achillis,  and  that  of  the 
triceps  muscle  of  the  arm.  Such  a  tap  or  blow  is  generally  answered  by 
a  contraction  in  the  muscle  or  set  of  muscles  connected  with  the  tendon, 
and  is  not  owing  to  mechanical  concussion  of  the  muscular  substance,  as 
Westphal  at  first  believed,  but  to  true  reflex  action,  the  centre  of  which  for 
the  legs  appears  to  be  situated  in  the  lower  portion  of  the  spinal  cord 
(Schultze  and  Fiirbringer).  It  is  best  shown  by  a  patient  being  made  to 
sit  on  a  table,  so  that  the  legs  dangle  about ;  the  tendon  of  the  rectus  is 
now  gently  struck,  when  the  foot  is  seen  to  be  jerked  forward.  That  it  is 
stimulation  of  the  nerves  of  the  tendon,  and  not  of  the  skin,  which  pro- 
duces this  phenomenon,  is  shown  by  the  circumstance  that  it  occurs  after 
the  skin  has  been  rendered  insensible  by  the  ether-spray,  and  that  it  may 
be  present  where  cutaneous  reflexion  is  diminished  or  gone,  and  vice 
versa. 

Now  tendinous  reflexion  appears  to  be  entirely  gone  in  ataxy  as  soon  as 
this  disease  has  become  fairly  developed ;  while  it  is,  on  the  contrary, 
greatly  increased  in  lateral  sclerosis.  Thus,  when  a  patient  suffering  from 
this  latter  complaint  is  told  to  stamp  on  the  floor  with  his  foot,  the  whole 
limb  is  thrown  into  a  state  of  tremor,  which  may  continue  for  hours. 
This  tremor  may  also  be  excited  by  suddenly  flexing  the  foot,  and  can  be 


1878.]     Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  343 

generally  arrested  by  extending  the  same.  It  thus  comes  to  resemble  the 
phenomenon  known  by  the  incongruous  name  of  "spinal  epilepsy."  Such 
reflex  movements  are  in  lateral  sclerosis  not  only  more  readily  induced  in 
those  tendons  in  which  they  habitually  appear  in  healthy  subjects,  but 
they  also  occur  in  other  tendons  in  which  they  are  usually  absent,  such  as 
those  of  the  tibiales  and  semitendinosus  muscles  of  the  lower,  and  the  bi- 
ceps, deltoid,  supinator,  and  extensor  digitorum  communis  muscles  in  the 
upper  extremity.  In  doubtful  cases  the  opposite  behaviour  of  tendinous 
reflexion  in  posterior  and  lateral  sclerosis  may  therefore  be  utilized  for  the 
purpose  of  diagnosis.  The  increase  of  the  phenomenon  in  lateral  sclerosis 
cannot  be  explained  by  irritation  of  the  gray  matter,  as  this  does  not  share 
in  the  affection,  but  has  to  be  accounted  for  by  the  influence  of  inhibition. 
The  centre  for  the  inhibition  of  reflex  movements  is  situated  in  the  cor- 
pora quadrigemina,  and  paths  for  its  conduction  are  found  in  the  lateral 
columns.  We  shall  therefore  be  justified  in  assuming  that  the  increase  of 
tendinous  reflexion  in  lateral  sclerosis  is  owing  to  the  cessation  of  arrival 
of  inhibitory  influence  from  the  brain  in  the  muscles,  from  interrupted 
connection. 

Symptoms  on  the  part  of  the  vaso-motor  nerves  and  of  those  which  pre- 
side over  nutrition,  are  rare  in  lateral  as  well  as  posterior  sclerosis,  unless 
the  lesion  has  invaded  other  portions  of  the  cord.  An  exception  to  this 
rule  is  however  found  in  some  forms  of  ataxy,  where  a  peculiar  affection 
of  the  joints,  more  particularly  of  the  knee,  shoulder,  elbow,  and  hip  is 
apt  to  occur.  The  joints,  as  well  as  the  subcutaneous  cellular  tissue  in 
their  neighbourhood,  become  subject  to  a  non-inflammatory  swelling,  which 
is  unattended  by  pain,  tenderness,  redness,  or  heat.  This  lesion  is  never- 
theless of  a  serious  nature,  as  it  leads  to  atrophy  of  the  epiphyses,  disloca- 
tion, and  consequent  deformity  and  uselessness  of  the  limbs.  Excessive 
fragility  of  the  bones  may  also  be  present.  These  symptoms  can  only  be 
owing  to  more  or  less  sudden  failure  of  nutrition  in  the  parts  affected ;  but 
it  has  not  yet  been  ascertained  which  portion  of  the  cord  is  to  be  held 
responsible  for  this  condition. 

The  principal  centre  for  the  movements  of  the  bladder,  rectum,  and  male 
organs  of  generation,  has  by  physiologists  been  found  in  the  lumbar  en- 
largement of  the  cord;  but  the  more  precise  seat  of  this  centre  has  not  yet 
been  ascertained.  Judging  from  pathological  observations,  I  should  say 
that  it  is  not  situated  in  the  lateral  columns,  for  in  lateral  sclerosis  there 
are  no  symptoms  pointing  to  loss  of  function  in  these  viscera.  It  is  true 
that  Dr.  Gray,  of  Long  Island  College,  has  quite  recently  recorded  a  case 
in  which  there  was  involuntary  action  of  the  bladder  if  the  desire  to  urinate 
was  not  quickly  gratified ;  but  this  is  most  exceptional,  and  most  likely 
owing  to  extension  of  the  disease  to  other  parts.  In  posterior  sclerosis, 
on  the  other  hand,  either  irritation  or  failure  in  the  action  of  the  bladder, 
bowel,  and  sexual  organs,  is  the  rule,  and  appears  at  a  comparatively  early 


344         Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  [Oct. 


stage  of  the  disease.  Total  loss  of  function  in  these  parts  is  only  observed 
in  the  later  period,  when  the  posterior  cornua  of  the  gray  matter  have  per- 
manently become  sclerosed.  Even  where  the  patient  is  unable  to  walk, 
the  sexual  function  may  still  be  in  existence,  as  shown  by  the  following 
case  which  is  now  under  my  care  at  the  Hospital  for  Epilepsy  and  Pa- 
ralysis, Regent's  Park: — 

J.  R.,  aged  40,  single,  a  commercial  traveller,  was  admitted  under  the 
care  of  Dr.  Althaus  on  January  25th,  1878.  He  lias  travelled  much  in 
the  tropics,  undergone  great  exposure  to  cold  and  heat,  and  lived  a  wild 
life,  exceeding  in  sexual  relations  as  well  as  in  drinking.  Five  years  ago 
he  had  an  attack  of  delirium  tremens.  He  also  has  had  a  soft  chancre 
and  gonorrhoea,  which  resulted  in  stricture  of  the  urethra,  but  never  had 
constitutional  syphilis.  Two  years  ago,  when  in  South  America,  he  first 
felt  difficulty  in  walking,  and  was  some  time  afterwards  admitted  into  the 
Hospital  of  Buenos  Ayres,  where  he  remained  three  months.  He  noticed 
that  he  walked  much  worse  in  the  dark  than  in  the  daytime,  and  that  he 
had  constantly  to  look  at  his  feet  for  guiding  the  movements  of  the  legs. 
He  got  better  and  worse  alternately,  but  two  months  ago  he  was  still  able 
to  walk  about,  and  could  at  a  stretch  go  on  for  three  miles.  One  day. 
however,  when  about  to  cross  a  street,  lie  had  to  jump  in  order  to  avoid 
being  run  over  by  a  cab.  This  seemed  to  give  him  a  strain  in  the  back, 
and  from  that  time  forward  he  has  gone  down  steadily. 

Present  state:  The  brain  is  quite  free  from  disease,  but  the  third  left 
cranial  nerve  is  affected,  there  being  paralysis  of  the  left  rectus  interims 
and  the  inferior  oblique  muscles.  In  consequence  of  this  the  patient  is 
unable  to  turn  the  left  eye  inwards  and  upwards.  There  is  crossed  diplo- 
pia and  divergent  strabismus.  There  also  appears  at  first  sight  to  be 
ptosis  of  the  left  upper  eyelid,  but  on  closer  examination  it  is  found  that 
the  levator  palpebral  superioris  muscle  is  not  paralyzed,  but  is  intention- 
ally put  out  of  action  by  the  patient  in  order  to  avoid  the  annoyance  of 
double  images;  for  the  eye,  although  habitually  closed,  can  be  opened  at 
request  without  any  difficulty.  The  ocular  muscles  of  the  right  eye  and 
all  the  other  cranial  nerves  are  quite  healthy. 

The  cord -affection  in  this  case  is  at  present  confined  to  the  lumbar  en- 
largement. The  arms  and  hands  are  in  their  normal  state,  and  there  is 
no  disease  of  the  thoracic  and  abdominal  viscera.  Incomplete  anaesthesia 
commences  in  the  hypogastric  region,  and  spreads  from  there  to  the  lower 
extremities,  being  particularly  marked  in  the  feet  and  legs,  and  less  so  in 
the  thighs  and  hips.  He  feels  the  ground  quite  soft,  like  cotton  or  velvet ; 
is  still  able  to  feel  the  prick  of  a  pin,  but  has  a  sensation  of  great  numb- 
ness in  the  legs.  The  power  of  walking  is  entirely  gone,  and  the  patient 
can  only  stand  when  supported  on  both  sides,  yet  he  is  well  able  to  cross 
one  leg  over  the  other  when  sitting,  and  has  no  difficulty  in  moving  the 
legs  in  the  recumbent  position.  The  nutrition  of  the  muscles  of  the  lower 
extremities  has  suffered  a  good  deal,  but  evidently  more  from  disuse  than 
from  disease  of  the  anterior  cornua,  for  they  respond  wrell  to  the  faradaic 
and  galvanic  current.  Cutaneous  reflex  excitability  is  preserved,  but  ten- 
dinous reflexion  absent.  The  bladder  is  weaker  than  formerly,  but  there 
is  only  occasionally  retention.  The  bowels  are  regular.  Sexual  desire  is 
absent,  and  the  power  diminished,  but  not  gone,  for  the  patient  is  occa- 
sionally subject  to  nocturnal  emissions  of  semen,  and  has  erections  on  first 
wraking  in  the  morning. 


1878.]     Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  345 


On  the  other  hand,  I  have  found  that  in  inflammation  of  the  anterior 
cornua  of  the  lumbar  enlargement,  with  consecutive  muscular  atrophy,  the 
bladder  and  rectum  continue  to  act  normally,  while  the  male  sexual  func- 
tion is  at  once  and  completely  destroyed.  It  therefore  appears  to  me 
probable  that  the  posterior  columns  are  not  the  centre,  but  contain  only 
the  paths  for  the  conduction  of  motor  impulses  to  the  bladder,  rectum,  and 
sexual  organs ;  that  the  true  centre  for  these  parts  is  situated  in  the 
central  gray  matter  ;  that  the  posterior  cornua  of  this  substance  are  the 
centre  for  the  bladder  and  rectum  ;  and  that  the  anterior  cornua  contain 
an  important  centre  for  the  male  sexual  organs. 

The  mode  of  development  of  both  lateral  and  posterior  sclerosis  is,  as  a 
rule,  extremely  chronic  and  protracted  over  years,  nay,  decennia.  In 
both,  the  morbid  process  usually  commences  in  the  lumbar  enlargement  of 
the  cord,  owing  to  which  the  symptoms  appear  simultaneously  and  to  an 
equal,  or  nearly  equal,  extent  in  both  lower  extremities.  The  disease  has 
a  tendency  to  remain  limited  to  this  neighbourhood  for  years,  but  to  spread 
within  it  from  one  set  of  nerve-cells  and  fibres  to  another,  so  as  to  gradu- 
ally disorganize  the  whole  structure.  There  is,  however,  no  continuous 
progress  of  this  sort,  but  it  goes  on,  as  it  were,  by  fits  and  starts ;  for  a 
time,  the  morbid  process  appears  arrested,  after  which,  mostly  owing  to 
unfavourable  external  influences,  a  fresh  start  in  the  wrong  direction  is 
made,  which  stops  again  at  a  certain  point.  The  course  of  the  complaint 
is  particularly  slow  where  the  patients  are  placed  in  favourable  conditions, 
and  are  not  obliged  to  expose  themselves  to  cold  and  wet,  or  to  undergo 
exertions  and  privations  ;  and  where,  in  addition  to  this,  they  resign  them- 
selves to  a  quiet  and  uneventful  life.  In  the  contrary  circumstances,  the 
development  of  the  disease  is  far  more  rapid. 

After  a  variable  time,  the  sclerosis  spreads  upwards  through  the  dorsal 
portion  of  the  cord  to  the  cervical  enlargement,  where  it  assumes  the  same 
course  of  slow  disintegration.  Even  then,  however,  neither  lateral  nor 
posterior  sclerosis  has  the  tendency  to  shorten  life,  unless  the  morbid 
process  spreads  more  transversely  through  the  organ,  when  cystitis,  bed- 
sores, and  blood-poisoning  are  apt  to  become  developed  ;  or  where  it  creeps 
up  to  the  medulla  oblongata  and  its  motor  nuclei,  when  death  takes  place 
from  failure  in  the  power  of  the  cardiac  and  respiratory  centres,  or 
through  inanition,  from  loss  of  the  power  of  swallowing.  In  other  cases, 
the  patient  succumbs  ultimately  to  certain  complications,  such  as  typhoid 
fever,  pulmonary  consumption,  bronchitis,  pneumonia,  affections  of  the 
heart  and  liver,  and  other  diseases  which  have  no  particular  connection 
with  the  sclerosis. 

There  are,  however,  some  peculiarities  in  the  course  of  both  affections 
to  which  a  short  allusion  must  be  made.  The  participation  of  the  cranial 
nerves  in  the  first  stage  of  posterior  sclerosis  is  one  of  them  ;  and  Ave  are 
therefore  led  to  think  that  ataxy  has,  even  in  the  beginning,  more  ten- 


346         Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  [Oct. 


dency  to  generalization  than  lateral  tabes.  In  the  latter,  it  is  not 
uncommon  that  the  clinical  aspect  of  the  case  is  at  first  more  like  that  of 
hemiplegia  than  paraplegia,  the  affection  beginning  in  one  leg  and  then 
creeping  up  to  the  arm  of  the  same  side ;  or  it  assumes  the  form  of  cer- 
vical paraplegia,  beginning  in  both  upper  extremities  and  gradually  descend- 
ing to  the  lower  ones.  Anomalies  of  this  description  also  occur  now  and 
then  in  posterior  sclerosis. 

In  cases  where  spasmodic  spinal  paralysis  assumes  the  form  of  hemi- 
plegia, the  clinical  features  of  the  case  resemble  very  closely  those  of 
cases  of  cerebral  hemorrhage,  with  consecutive  sclerosis  of  the  crossed 
pyramidal  column  of  the  cord,  of  which  the  following  is  an  instance  : — 

C.  B.,  a  fish -salesman,  aged  40,  married,  admitted  under  the  care  of 
Dr.  Althaus  on  February  14th,  1878.  Seven  years  ago,  while  attending 
to  his  business,  he  had  an  attack  in  which  he  to  some  extent  lost  his 
speech  and  the  use  of  his  left  side.  He  could  speak,  but  thickly  and  with 
an  effort,  and  could  walk  a  little,  but  kept  falling  down  as  he  went  on. 
He  was  admitted  into  the  London  Hospital,  Whitechapel,  but  was  not 
able  to  resume  his  business  when  he  left  it.  Twelve  months  after  the 
first  attack  he  had  another,  which  was  more  severe  than  the  first,  and 
took  the  speech  and  use  of  the  left  side  away  more  completely  than  the 
first.  Consciousness  was  also  lost  for  sonic  time.  He  attributed  hi<  ill- 
ness to  anxiety  and  excitement  in  business,  and  had  had  very  heavy  losses 
just  previous  to  the  first  attack.  His  parents  were  nervous  people  and 
had  died  early;  and  he  had  for  some  time  previous  to  the  first  attack  suf- 
fered from  headache  and  indigestion. 

On  examination,  it  was  found  that  the  speech  was  somewhat  thick  and 
indistinct,  but  quite  fluent.  There  was  no  loss  of  words.  The  patient's 
manner  is  peculiar,  somewhat  silly  ;  his  memory  is  not  good.  The  cranial 
nerves  are  quite  healthy  ;  there  is  loss  of  power  in  the  left  side,  combined 
with  muscular  rigidity.  The  arm  is  abducted  from  the  body,  and  the 
elbow,  wrist,  and  fingers  are  in  a  state  of  extension.  There  is  great  diffi- 
culty in  flexing  and  supinating  the  arm,  and  in  bending  the  hand  and 
fingers,  and  considerable  resistance  to  passive  movements  in  that  direction. 
The  gait  of  the  patient  is  most  characteristic  and  indicative  of  lateral 
sclerosis  ;  he  walks  on  tiptoe  with  the  left  leg,  which  seems  to  be  fixed  in 
a  vice,  so  awkward  and  slow  are  its  movements.  The  foot  is  inclined  to 
scrape  the  ground  as  it  shuffles  along,  and  there  is  tendency  to  fall  for- 
ward on  that  side.  The  rigidity  is  marked  in  the  rectus  femoris,  and 
there  is  difficulty  in  flexing  the  leg  and  foot.  The  reflex  action  of  the 
skin  and  of  the  tendons  is  increased,  more  especially  in  those  of  the 
triceps  of  the  arm  and  the  rectus.  There  is  slight  wasting  of  the  muscles, 
but  not  more  than  could  be  attributed  to  disuse  ;  and  the  faradaic  and  gal- 
vanic response  is  slightly  less  than  on  the  healthy  side.  Sensation  is  not 
affected,  and  the  chest  and  abdominal  organs  are  healthy. 

It  is  evident  that  in  this  case  there  was  at  first  hemorrhage  from  one  or 
several  miliary  aneurisms  in  the  arterioles  springing  from  the  Sylvian 
artery  and  supplying  the  right  corpus  striatum,  thus  causing  left  hemi- 
plegia. There  was  never  any  real  aphasia,  but  only  such  affection  of 
speech  as  is  met  with  apart  from  disease  in  Broca's  convolution.    In  con- 


1878.]     Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  347 


sequence  of  the  effusion  of  blood,  secondary  sclerosis  (as  first  described  by 
Tiirck,  of  Vienna)  set  in  in  the  posterior  portion  of  the  lateral  column, 
which  is  composed  of  fibres  derived  from  the  opposite  cerebral  hemisphere  ; 
and,  as  the  same  portion  of  the  cord  is  also  affected  in  spasmodic  spinal 
paralysis,  the  physiological  similarity  in  the  symptoms  is  easily  under- 
stood. The  cause  and.  history  of  the  two  maladies  are,  however,  quite 
different,  the  one  being  primary,  the  other  secondary  sclerosis.  Ana- 
tomically, they  differ  likewise,  inasmuch  as  the  gray  patches  in  secondary 
sclerosis  are  rounded,  while  in  the  primary  form  they  are  wedge-shaped  ; 
likewise,  in  primary  sclerosis,  these  patches  spread  exteriorly  as  far  as  the 
pia  mater,  while  in  the  secondary  form  they  stop  short  at  some  distance 
from  that  membrane. 

The  chief  cause  of  lateral  tabes  appears  to  be  cold.  Sleeping  in  a 
damp  bed,  getting  a  thorough  wetting  during  a  day's  shooting,  etc.,  is 
generally  mentioned  by  the  patients.  Whether  hereditary  tendency,  lead- 
poisoning,  sexual  excesses,  and  syphilis,  play  any  part  in  the  causation  of 
the  diseases,  remains  uncertain.  The  patients  I  have  seen  were  all  male.-, 
between  35  and  50  years  of  age ;  yet  it  occurs  in  women  likewise,  and 
also  later  and  earlier  than  the  period  just  mentioned. 

The  causes  of  posterior  sclerosis  are  much  better  known.  Some  forms 
of  it  are  clearly  hereditary ;  but  more  frequently  the  neurotic  constitution 
is  not  marked  in  the  parents  of  the  patients.  Cold,  sexual  excesses, 
over-exertion,  and  depressing  mental  emotions  are  the  most  frequent 
amongst  them  ;  and  the  disease  is  particularly  developed  where  all  these 
different  agents  act  together.  Accidents,  more  especially  a  fall  from  horse- 
back, are  often  mentioned  in  the  history  of  these  cases ;  yet  ataxy  is 
rarely  seen  after  railway  accidents,  and  in  those  cases  where  injury  was 
mentioned  to  me  as  a  cause,  the  interval  between  its  occurrence  and  the 
outbreak  of  the  malady  was  so  long  that  it  appeared  difficult  to  assume  a 
causal  connection  betwixt  the  two. 

The  prognosis  in  both  lateral  and  posterior  sclerosis  is,  in  a  general 
way,  unfavourable,  as  soon  as  the  symptoms  have  become  fully  developed, 
yet  every  physician  who  has  seen  much  of  these  diseases  knows  of  some 
cases  in  which  complete,  or  almost  complete  recovery  has  taken  place. 
Mostly,  however,  we  must  be  satisfied  if  we  succeed  in  arresting  the  pro- 
gress and  relieving  the  symptoms  of  the  complaint.  The  prognosis  depends 
greatly  upon  external  circumstances  and  the  mode  of  life  adopted  by  the 
patient.  Those  who  have  to  work  for  their  living  are  worse  off  in  this 
respect  than  those  born  with  the  silver  spoon  in  their  mouths  ;  and  the  rake 
dies  more  quickly  than  the  philosopher.  Two  of  the  most  marked  cases 
of  ataxy  which  I  ever  saw,  occurred,  one  in  a  member  of  the  hereditary 
branch  of  the  British  Legislature,  who,  being  of  slight  physique  and  calm  and 
fastidious  by  temperament,  surrounded  himself  with  everything  that  may 
adorn  life,  and  found  consolation  for  his  infirmity  in  the  arts  and  litera- 


348         Althaus,  Ataxy  and  Spasmodic  Spinal  Paralysis.  [Oct. 


ture.  He  lived  to  the  age  of  sixty,  after  having  been  subject  to  the  com- 
plaint for  upwards  of  thirty  years,  and  having  hardly  ever  experienced 
really  severe  suffering.  The  other  case  was  that  of  a  hot-tempered  Irish- 
man, who,  after  having  made  a  fortune  in  Australia',  returned  to  England 
to  spend  his  life  in  the  wildest  excitement,  intrigues,  and  debauchery  of 
every  description.  He  died  within  four  years  from  the  outbreak  of  the 
malady,  after  having  undergone  the  most  frightful  tortures  which  man  may 
be  called  upon  to  endure,  and  after  having  seen  an  originally  herculean 
constitution  undermined  and  wasted  in  a  comparatively  short  time. 

The  treatment  of  both  diseases  must  be  persevered  in  systematically  for 
a  considerable  time  if  any  real  success  is  to  be  achieved.  Rest  is  of  great 
importance,  and  we  must  endeavour  to  arrange  all  conditions  of  life  as 
favourably  as  possible  for  the  patients.  Of  specifics  we  have  two,  viz., 
nitrate  of  silver  and  ergot  of  rye.  Some  great  cures  have  been  effected 
by  the  use  of  either  of  these  medicines,  more  particularly  in  the  earlier 
stages  of  the  complaint ;  but,  in  the  majority  of  cases,  and  at  a  later  period, 
their  effect  is  disappointing.  Nitrate  of  silver  should  be  given  in  doses  of 
from  ^  to  ^  grain,  and  must  be  stopped  after  120  grains  have  been  given. 
The  urine  should  be  tested  frequently  and  the  remedy  omitted  if  albumin- 
uria be  induced  by  it.  Ergot  is  given  either  as  Bonjean's  ergotine,  in 
doses  from  1  to  5  grains,  or  as  the  liquid  extract,  in  doses  from  20  to  120 
minims.  I  liave  completely  cured  two  cases  of  ataxy  with  drachm  doses 
of  the  latter  preparation,  three  times  a  day;  and  at  no  period  during  its 
administration,  which  in  one  instance  extended  to  six,  and  in  another  to 
eight  months,  were  there  any  symptoms  of  ergotism.  Damiana  likewise 
appears  to  have  a  special  influence  on  the  cord  in  these  cases  ;  I  give  it  in 
doses  of  20  to  60  minims  of  the  liquid  extract.  Iodide  of  potassium, 
strychnia,  and  arsenic  are  generally  ineffective.  The  constant  galvanic 
current  is  useful  for  the  relief  of  pain,  paralysis  of  the  ocular  muscles, 
anaesthesia,  and  vesical  debility.  If  used  sufficiently  early,  it  appears 
capable  of  arresting  the  disease.  It  is,  however,  essential  for  success  that 
a  gentle  and  perfectly  steady  current  should  be  used,  by  large  electrodes, 
for  a  short  time,  and  that  all  shocks,  Voltaic  alternatives,  or  powerful  and 
prolonged  applications  be  avoided.  A  judiciously  directed  hydrothera- 
peutical  treatment,  and  the  thermal  brines  of  Rehme  and  Nauheim  in 
Germany,  and  Droitwich  in  England,  are  also  useful.  For  the  relief  of 
the  pain  of  ataxy,  I  can  strongly  recommend  the  salicylate  of  soda,  in 
twenty  grain  doses  several  times  a  day.  It  often  acts  better  than  the 
hypodermic  injection  of  morphia  or  chloral,  but  is  likewise,  as  all  other 
remedies,  occasionally  disappointing.  Special  attention  must  be  given  to 
the  state  of  the  bladder  and  rectum.  For  catarrh  of  the  bladder  with 
ammoniacal  decomposition  of  the  urine,  the  salicylate  of  soda  in  the  doses 
just  mentioned  is  useful ;  while  for  constipation,  the  Hunyadi  Janos  water 
and  allied  remedies  may  be  given.    Where  symptoms  of  general  debility 


1878.]     De  Rosset,  Action  of  Muscle  of  Accommodation.  349 

and  impaired  nutrition  are  prominent,  phosphorus  and  cod-liver  oil,  alone 
or  in  combination,  have  proved  to  me  most  valuable. 

For  lateral  sclerosis,  ergot  and  nitrate  of  silver  likewise  deserve  a  trial. 
For  the  relief  of  the  muscular  rigidity  and  twitches,  the  bromides  of 
sodium,  potassium,  and  ammonium  may  be  given.  I  have  sometimes  use- 
fully combined  them  with  extractum  physostigmatis,  in  doses  from  J  to 
J  grain,  and  succus  conii.  The  motor  debility  is  often  successfully  com- 
bated by  galvanization  of  the  cord  and  suffering  nerves ;  and  the  use  of 
sulphur  baths  at  a  temperature  of  98°  or  even  100°  may  prove  serviceable. 


Article  III. 

The  Muscle  of  Accommodation,  and  its  Mode  of  Action.  By  M.  J. 
De  Rosset,  M.D.,  of  New  York,  Ophthalmic  Surgeon  to  Dispensary  Holy 
Trinity,  Assistant  Surgeon  New  York  Eye  and  Ear  Infirmary,  etc.  etc. 

The  physiological  role  performed  by  the  anatomical  elements  within 
the  eye  for  the  purpose  of  adapting  vision  to  varying  distances  has  never 
been  satisfactorily  explained;  and  the  inherent  difficulties  which  oppose  an 
explanation  have  hitherto  appeared  so  insuperable,  that  physiologists  gen- 
erally, and  ophthalmologists,  whom  the  matter  more  nearly  concerns,  have, 
in  despair,  been  forced  to  a  tacit  assent  to  the  Helmholtz  theory  as  the 
least  objectionable  yet  propounded. 

The  difficulties  in  solving  this  question  issue  not  so  much  out  of  our 
ignorance  of  the  anatomy  of  the  structures  involved  (for  this  has  been 
very  perfectly  demonstrated),  as  out  of  our  failure  to  recognize  that  some 
of  them  cannot,  for  mechanical  reasons,  perform  their  role  in  the  manner 
which  the  prevailing  hypotheses  demand.  Whence  this  failure,  it  is  im- 
possible to  say,  unless  it  is  from  our  having  been  fettered  by  the  weight  of 
authority  and  tradition  ;  and  it  may  seem  almost  madness  to  disturb  the 
peaceful  repose  by  engaging  in  a  work  that  has  for  its  purpose  the  over- 
throw of  views  upon  which  is  founded  so  large  a  portion  of  what  is  held  as 
sound  in  ophthalmic  practice.  Other  difficulties  encountered  in  the  in- 
quiry come  from  the  uncertain  state  of  our  knowledge  concerning  the 
function  and  influence  of  the  nerves  which  are  known  to  be  supplied  to 
the  ciliary  muscle,  and  as  long  as  we  remain  ignorant  upon  this  important 
point,  we  should  be  very  careful  in  inferences  as  to  the  bearing  which 
physiological  experiments  on  the  nerves,  and  the  disturbances  caused  by 
obscure  pathological  processes,  have  upon  the  question.  Still  another  dif- 
ficulty is  in  the  notion,  almost  universally  entertained,  respecting  the 
action  of  mydriatics  and  myotics.  This  notion,  it  is  well  known,  has  not 
been  derived  from  actual  observation,  but  is  wholly  assumed  in  a  shape 


350 


De  Rosset,  Action  of  Muscle  of  Accommodation.  [Oct. 


to  harmonize  with  the  theories  of  accommodation  ;  but  so  far  from  its 
being  correct,  the  few  direct  observations  which  have  been  made  of  the 
movements  of  the  ciliary  muscle  under  the  influence  of  a  mydriatic  (I 
refer  to  those  of  Hensen  and  Voelckers)  indicate,  with  an  approach  to  cer- 
tainty, that  this  muscle  contracts,  is  tetanized  not  paralyzed,  when  atropia 
is  applied  to  it.  The  experiments  of  Coccius  and  others  might  also  be 
cited  in  support  of  this  view,  but  special  allusion  to  them  must  be  deferred 
to  a  later  portion  of  this  paper. 

There  are  several  facts  so  well  established  that  they  may  be  taken 
as  the  starting-point  for  this  inquiry.  I  refer  to,  1,  the  sufficiency  of 
the  varying  degrees  of  convexity  of  the  lens  to  account  for  all  the  focal 
changes  in  the  dioptric  system  of  the  eye  ;  2,  the  inherent  elasticity  of  the 
lens  ;  3,  the  common  consent  that  the  ciliary  muscle  is  the  only  structure 
which  actuates  the  lens. 

The  first  of  these  propositions  maybe  accepted  absolutely  as  stated;  but 
I  would  mention,  if  only  in  illustration  of  one  of  the  many  curious  phases 
which  this  question  has  assumed,  that  Mr.  Dudgeon,  of  England,  has  writ- 
ten a  paper,  in  a  serious  vein,  to  show  that  the  lens  does  not  affect  the 
accommodation  by  changing  its  convexity,  but  by  rotating  itself  from 
without  inwards.  His  explanation  is  probably  as  lucid  as  his  idea  will 
admit. 

The  second  proposition,  likewise,  has  few  opponents  ;  but  some  German 
physiologists  who  hold  to  the  "compressor  lentis  accommodatorius"  theory 
of  Langenbeck,  think  that  the  lenticular  elasticity  restores  a  flatness  to 
the  lens  when  the  alleged  compressive  action  of  the  muscle  is  withdrawn. 

The  third  proposition  is  sustained  by  the  manifest  significance  in  the 
location  and  relations  of  the  ciliary  muscle. 

Starting  from  these  facts,  my  own  experiments  and  study  lead  me  into 
a  wide  divergence  from  the  commonly  accepted  view,  and  I  hope  to  be 
able  to  show  that  the  play  of  the  ciliary  muscle  produces  effects  quite  the 
reverse  of  those  which  are  now  ascribed  to  it. 

Let  us  first  review  the  histology  and  anatomy  of  this  muscle,  and  con- 
sider carefully  its  contiguous  relations,  for  these  lie  at  the  very  root  of  the 
conclusions  to  be  hereinafter  expressed.  "We  may  then  examine  the  mus- 
cle in  action,  analyzing  the  various  objective  and  subjective  phenomena 
associated  with  it,  and  inquire  into  the  influence  of  atropia  and  eserine ; 
and,  lastly,  whether  the  conditions  which  are  now  attributed  to  paralysis 
and  spasm  have  been  rightly  interpreted,  and  whether  there  is  anything 
in  them,  from  an  etio]ogical  point  of  view,  to  invalidate  conclusions  to 
which,  it  will  be  claimed,  the  anatomical  facts  irresistibly  lead. 

The  fibres  of  this  ciliary  muscle  resemble  those  of  all  smooth  muscles  in 
being  pale  and  unstriped,  and  in  the  character  of  their  nuclear  elements. 
The  resemblance  also  exists  in  their  ordinary  movements  being  associated 


1878.]     De  Rosset,  Action  of  Muscle  of  Accommodation.  351 

ones,  rather  than  independent,  and  in  their  being  peculiarly  subject  to 
reflex  influences. 

They  lie  chiefly  in  a  meridional  direction,  forming  a  part  of  the  cho- 
roidal tunic,  their  greater  bulk  being  anterior  to  the  equator ;  but  some  fas- 
ciculi are  traceable  backw  ards,  quite  up  to  the  optic  nerve  entrance.  Like 
in  all  smooth  muscles,  in  addition  to  longitudinal  fibres  there  are  others 
which  anastomose  in  a  most  plexiform  network,  their  general  direction 
being  crosswise.  In  many  eyes  these  are  found  as  far  posteriorly  as  the 
equator ;  but  they  usually  exist  in  greater  preponderance  at  the  anterior 
part  of  the  choroid,  forming  with  the  meridional  fibres,  as  these  converge, 
the  bulky  portion  of  the  muscle  known  as  the  ciliary  body  and  processes. 

Upon  meridional  section  of  the  muscle  in  its  anterior  portion,  these 
anastomosing  fibres  present  such  an  appearance  as  led  Langenbeck  and 
Midler  to  believe  that  they  constituted  an  annular  mass,  wThich  the  imagi- 
nation easily  pictured  was  ready  to  actuate  the  lens  by  pressure  upon  its 
margin.  If  this  had  been  sustained,  the  question  of  so-called  active  ac- 
commodation wrould  have  been  completely  solved  ;  but  later  investigations 
have  disproved  its  possibility,  showing  that  the  ciliary  body  not  only  does 
not  touch  the  lens,  but  that  the  interval  between  it  and  the  lens  margin  is 
not  sensibly  diminished,  even  under  the  most  vigorous  adjustment  for  near 
vision. 

The  general  shape  of  this  thickened  part  of  the  muscle  is  triangular, 
writh  the  base  looking  forwards  and  towards  the  axis  of  the  eye ;  and 
Iwanoff  and  others  have  attempted  to  show7  that  variations  in  this  triangle 
are  characteristic  of  the  several  metropic  states,  and  due  to  hypertrophy 
or  atrophy  induced  by  variations  in  the  accommodative  activities.  Loring 
has  showm  that  these  triangles  are  probably  in  no  w  ay  connected  with  the 
exercise  of  the  accommodation,  but  exist  as  anatomical  consequences  of  a 
longer  or  shorter  optic  axis.  This  may  probably  be  accepted  as  a  fact, 
but  no  explanation  is  given  for  it.  It  seems  to  me  clear  that  these  tri- 
angles, which  embrace,  or  constitute,  the  ciliary  body  and  processes,  have 
a  true  geometric  reason  for  their  existence  in  varying  shapes.  They  exist 
of  necessity,  because  the  meridional  fibres,  as  they  dip  inward  towards  the 
anterior  pole  and  axis,  must  become  infolded  and  form  prominent  plaits, 
the  progressively  contracting  zone  not  furnishing  space  enough  for  their 
expansion  into  a  thin  smooth  layer,  as  nearer  the  equator.  If  the  meridi- 
onal fibres  were  continued  in  bulk  backwards  towards  the  posterior  pole 
of  the  eye,  we  should  have  also  in  the  vicinity  of  the  fovea  a  mass  of 
muscle  similar  to  the  ciliary  body.  I  do  not  think  that  apart  from  its 
relation  to  the  accommodation  the  ciliary  body  has  any  other  purpose  or 
function  than  to  accommodate  the  rich  vascular  and  nerve  supply  of  that 
region,  unless  it  be  to  furnish  some  support  to  the  vitreous  at  a  point 
which,  if  it  were  absent,  wrould  be  very  feeble.  As  to  the  variations  in 
the  triangular  shape  of  the  ciliary  body,  some  explanation  of  them  may 


352         De  Rosset,  Action  of  Muscle  of  Accommodation.  [Oct. 


be  had  if  we  consider  that  the  hypermetropic  eye  resembles  an  oblate 
sphere,  and  that  in  the  sudden  dip  and  flatness  of  the  great  circles,  as  they 
approach  the  pole,  the  fibres  of  the  muscle  must  be  infolded  more  sud- 
denly, and  in  a  shape  characteristic  of  the  triangle  in  eyes  of  this  re- 
fraction ;  but  the  myopic  eye  is  more  prolate  in  its  sphericity,  and  as 
the  great  circles  dip  more  gradually  towards  the  pole,  so  the  muscle 
would  be  more  gradually  infolded,  and  have  its  reduplications  extend  me- 
ridionally  over  a  greater  length. 

If  the  ciliary  muscle  be  divided  in  a  direction  perpendicular  to  the 
meridians  the  anastomosing  fibres  will  not  be  well  displayed,  but  the 
nuclear  elements  of  the  longitudinal  fibres  become  conspicuous  ;  but  if  the 
division  be  made  meridionally  the  longitudinal  fibres  will  be  shown  in 
their  length,  and  the  nuclei  of  the  anastomosing  fibres  will  become  visible, 
with  sections  of  ovoid  shape,  varying  according  to  the  angle  at  which  the 
incision  crossed  them. 

The  function  of  the  anastomosing  fibres  is  not  an  independent  one : 
they  contract  consensually  with  the  others,  but  do  not  influence  the  con- 
vexity of  the  lens.  They  serve  only  as  a  remora  to  bind  the  longitudinal 
bundles  together,  and  thus  render  more  uniform  the  pressure  exerted  by 
the  muscle  as  a  whole  on  the  intraocular  contents. 

"We  have  thus  seen  that  the  anastomosing  fibres  and  the  ciliary  body 
and  processes  have  no  special  relation  to  the  lenticular  changes,  and  in 
corroboration  of  this  I  may  mention  that  the  mass  has  often  been  com- 
pletely divided  for  surgical  purposes  without  materially  affecting  the  power 
and  range  of  the  accommodation. 

Let  us  return  now  to  the  longitudinal  fibres.  As  has  been  said,  these 
lie  side  by  side,  in  a  thin  layer,  in  an  antero-posterior  direction,  and 
form  a  part  of  the  tunica  choroidea.  Posterior  to  the  equator  the}'  are 
blended  with  the  connective  tissue  of  the  choroid,  but  some  fibres  may  be 
traced  well  backwards  towards  the  macula.  This  connection  is  a  very 
firm  one,  and  so  arranged  that  the  muscle  exerts  no  traction  on  the  chorio- 
capillaris  and  retina,  as  originally  conceived  by  Briicke,  and  recently 
urged  by  Dr.  Thomson,  of  Philadelphia,  in  an  attempt  to  show  that  astig- 
matism may  be  produced  by  the  independent  contraction  of  fasciculi 
lying  in  different  meridians.  This  connective  tissue  may  be  regarded  as 
a  true  posterior  tendon  of  the  muscle,  holding  it  in  fixed  relation  with  the 
ring  around  the  optic  nerve  entrance.  These  straight  fibres,  as  they  pass 
forwards,  divide  near  the  anterior  end  of  the  muscle  into  two  portions,  or 
heads ;  the  outer  one,  following  the  general  contour  of  the  globe,  is  firmly 
attached  to  the  corneo-scleral  line  by  the  ligamentum  pectinatum,  while 
the  inner  one,  which  separates  from  the  other  a  little  in  front  of  the  ora 
serrata  retinas,  dips  inwards,  with  a  smaller  curve,  and  terminates  in  a 
thick,  annular,  triangular  mass,  the  ciliary  body,  whose  lumen  is  a  little 
larger  than  the  diameter  of  the  lens  which  lies  almost  within  its  embrace. 


1878.]     De  Eosset,  Action  of  Muscle  of  Accommodation.  353 

This  inner  head  is  firmly  attached  to  the  zonula  ciliaris,  or  Zinnii,  which, 
in  its  turn,  is  intimately  united  by  brush-like  processes  with  the  capsule  of 
the  lens.  Thus  we  see  the  ciliary  muscle  forming,  by  means  of  its  inner 
head  and  the  zonule  and  lens  in  front,  a  complete  inner  envelope,  or  tunic, 
to  the  globe.  The  zonule  bears  such  an  important  relation  to  this  muscle 
that  we  must  give  it  a  brief  notice. 

It  has  deep-seated  attachments,  as  far  back  as  the  sequator  oculi,  to  the 
areolar  net-work  of  the  vitreous,  and  to  the  membrana  limitans  as  far 
forward  as  the  ora  serrata.  Anterior  to  that  point  it  is  free  until  it  reaches 
the  corpus  ciliare,  to  which  it  is  firmly  attached,  thence  passing  on  to 
unite  with  the  capsule  of  the  lens. 

Of  the  developmental  history  of  the  zonule,  whether  from  the  vitreous, 
corpus  ciliare,  or  capsule,  unfortunately  little  is  known.  It  only  exists 
late  in  the  embryo  after  the  vessels  which  develop  the  capsule  have  disap- 
peared. It  is,  however,  not  of  the  nature  of  connective  tissue,  and,  there- 
fore, it  is  proper  to  infer,  not  of  the  same  genetic  origin  as  the  trabecule 
of  the  vitreous.  But  for  some  radial  fibres  in  it  it  might  be  said  to  be 
hyaline  in  structure,  and  it  possesses,  in  spite  of  authors'  assertions  to  the 
contrary,  but  little,  if  any,  contractility.  It  must  be  regarded  as  some- 
what unique  in  its  histological  character,  and  is  charged  with  a  unique 
function,  which  constitutes  it  at  once  a  true  tendon  to  the  ciliary  muscle. 

Such  is  a  concise  and,  so  far  as  is  essential  to  our  object,  I  trust,  a  lucid 
statement  of  the  anatomy  of  these  parts,  made  in  accordance  with  the 
latest  and  most  trustworthy  authorities,  without  an  attempt  to  modify  it, 
however  slightly,  into  an  adaptation  to  any  physiological  theory. 

It  must  be  now  evident  that  the  immediate  effect  produced  by  the  con- 
traction of  these  straight  fibres  is  a  tension  exerted  in  an  antero-posterior 
direction  only.  This  tension  is  made  practically  between  two  points,  the 
lin.  supra-choroid.  and  the  corneo-scleral  line,  and  tends  probably  to  ap- 
proximate these  points  ;  but  as  pressure  is  simultaneously  made  upon  the 
semifluid  intra-ocular  contents  by  these  fibres  and  the  anastomosing 
ones,  an  approximation  is  wholly  prevented,  and  the  two  points  do  not 
change  their  relative  distance ;  the  muscle  becomes  tenser,  but,  as  we 
shall  see  directly,  what  actual  movement  it  makes  is  confined  to  its  inner, 
or  free,  head.  And  this  might  be  inferred  a  priori,  since  the  only  essen- 
tial function  of  the  muscle  is  to  actuate  the  lens  which  is  connected  solely 
with  this  inner  head.  That  the  tension  transmitted  through  the  outer 
head  (we  may  call  it  the  corneal  head,  to  distinguish  it  from  the  corpus 
ciliare,  or  lenticular  head,)  is  not  capable  of  shortening  the  polar  diameter 
of  the  globe  is  rendered  almost  certain  by  further  anatomical  considera- 
tions. The  ciliary  muscle,  as  a  part  of  one  of  the  tunics  of  the  eye,  is 
closely  applied  to  the  inner  surface  of  the  sclerotic,  but  connected  with  it, 
if  at  all,  only  in  the  loosest  manner.  When  the  muscle  contracts,  its  tend- 
ency is  to  separate  from  the  sclerotic  to  form  a  chord,  of  which  the  sclero- 
No.  CLII  Oct.  1878.  23 


354         De  Rosset,  Action  of  Muscle  of  Accommodation.  [Oct. 

tic  would  be  the  arc.  But  actual  separation  of  the  two  would  be  impossible 
unless  the  space  remaining  were  instantly  filled  (for  which,  obviously,  no 
provision  is  made),  so  the  sclerotic  follows,  of  necessity,  the  retreat  of  the 
muscle,  by  virtue  of  the  counter-extension  which  the  pressure  upon  the 
vitreous  exerts  upon  the  poles  of  the  globe.  The  effect  of  this  antero- 
posterior extension  is  to  elongate  slightly  the  vitreous  body,  and  to  press 
against  the  lens  in  front,  but  it  cannot  advance  this,  because  a  forward 
movement  of  the  lens  is  restrained  by  the  synchronous  backward  traction 
transmitted  through  the  lenticular  head  of  the  muscle.  It  must  be  re- 
membered that  these  actions  and  movements  are  extremely  minute  in 
quantity,  to  be  expressed  by  mere  fractions  of  a  mm.,  as  may  be  shown 
by  imitating  them  with  a  loose,  spherical,  inelastic  bag  filled  to  the  same 
manometric  tension  that  the  eye  presents. 

I  may  mention  here,  although  not  exactly  in  place,  that  I  have  made  the 
mathematical  calculations  necessary  to  show  the  difference  in  diameter  of  the 
lens  during  the  two  maximum  opposite  states  of  adjustment,  and  I  find  that 
less  than  \  mm.  change  in  diameter  is  sufficient  to  account  for  the  extremes  of 
alteration  in  convexity.  Now,  as  this  change  is  effected  wholly  by  the  alter- 
nate relaxation  and  tension  of  the  ciliary  muscle,  the  amount  to  be  ascribed 
to  each  meridian  of  straight  fibres  is  about  TL  mm.,  which  represents  the 
extent  to  which  any  observed  point  of  the  ciliary  body  would  advance  or 
recede  in  its  extreme  movements,  a  distance  obviously  too  small  to  be 
noted  by  the  means  used  by  those  observers  who  have  engaged  in  the 
controversy  respecting  the  movements  of  the  ciliary  body  in  accommoda- 
tion. My  own  observations  upon  this  point  have  been  limited  to  two 
cases  :  one  a  large  iridectomy,  made  for  glaucoma,  and  one  an  aphakial 
eye,  in  which  the  iridectomy  was  rather  larger  than  usual,  and  perfectlv 
unobstructed  by  opacities  of  any  kind.  In  the  first  case  (an  intelligent 
physician,  aged  50,  with  ^  =  yL),  the  observations  were  repeatedly  and 
carefully  made,  the  patient  being  trained  to  a  complete  and  rapid  transfer- 
ence of  vision,  to  and  fro  from  r  top,  and  upon  no  occasion  could  I  observe 
the  slightest  alteration  of  the  interval  between  the  ciliary  body  and  the 
lens  margin,  although  the  observations  were  made  with  a  magnifier.  Of 
course,  at  this  age,  the  lens  had  lost  a  large  portion  of  its  plasticity,  and 
the  excursions  of  the  ciliary  body  would  be  expected  to  be  greater  than 
those  of  the  lenticular  margin  ;  nevertheless  no  appreciable  diminution  of 
the  ciliar-lenticular  interval  could  be  detected.  The  observations  were 
continued  from  time  to  time  with  atropia  and  eserine,  but  always  with  the 
same  negative  results. 

The  second  case  was  a  lady,  aged  52,  upon  whom  I  had  operated  for 
extraction  of  the  lens,  making  an  unusually  large  iridectomy,  extending 
well  up  to  the  attached  periphery  of  the  iris.  The  pupil  was  perfectly 
clear,  and  she  had  V  =  §§.  The  experiments  were  conducted  with 
and  without  atropia  and  eserine.    The  same  negative  conclusions  were 


1878.]     De  Rosset,  Action  of  Muscle  of  Accommodation.  355 

reached  as  to  the  advance  and  recession  of  the  ciliary  body  when  observed, 
first,  without  any  application,  and  then  with  eserine  ;  but  recession  of  the 
ciliary  was  noticeable  when  the  effect  of  a  strong  solution  of  atropia 
(1  :  120)  was  watched  from  the  moment  of  its  instillation.  If  the  lens 
had  been  present,  and  I  had  watched  for  this  recession  by  measuring  the 
ciliar-lenticular  interval,  I,  perhaps,  would  not  have  detected  it,  as  the 
lens  margin  always  follows  the  movement  of  the  muscle,  and  in  the  same 
degree.  I  am  convinced  that  in  cases  of  extraction  the  anterior  visible 
head  of  this  ciliary  muscle  always  recedes  a  little,  by  slight  structural 
shortening  (of  the  myolemma),  it  having  lost  the  counter-extension  ex- 
erted by  the  resiliency  of  the  lens  substance ;  and  this  always  takes  place 
to  the  degree  permitted  by  the  posterior  capsule  in  passing  to  a  less  con- 
cave or  even  to  a  plane  or  convex  condition.  Incidentally  I  may  men- 
tion here  that  I  have  had  an  opportunity  of  examining  an  eye  to  discover 
the  changes  which  followed  a  successful  cataract  extraction,  the  patient 
dying  six  years  after  the  operation.  The  bulb  was  frozen  with  atomized 
rhigolene,  and  upon  section  it  was  found  that  the  lenticular  fossa  had  dis- 
appeared, and  the  capsule  which  here  forms  the  limiting  membrane  of  the 
vitreous  had  bulged  forward,  and  become  convex,  in  the  same  radial  curve 
as  the  vitreous  surface  elsewhere  presented.  I  did  not  know,  at  the  time 
the  observations  were  made  (1875),  that  other  opthalmologists  had  theo- 
retically anticipated  the  results  of  my  dissection. 

My  observations  with  atropia  correspond  with  those  of  Coccius,  though 
my  inferences  differ  from  his. 

It  becomes  apparent  from  this  anatomical  study  that  the  ciliary  muscle, 
quoad  its  outer  or  corneal  head,  cannot  approximate  its  two  points  of  attach- 
ment, and  consequently  it  is  impossible  that  its  contractions  should  relax 
the  zonule,  and  so  give  play  to  the  elasticity  of  the  lens.  This  is  rendered 
evident  by  the  general  anatomical  features  of  the  muscle,  and  by  the  points 
of  attachment  of  the  zonule.  In  the  lenticular  head  of  the  muscle  the  pro- 
portion of  fibres  is  much  greater  than  in  the  corneal  head,  and  hence  the 
actual  amount  of  movement  described  by  the  lenticular  head  must  be 
greater  than  that  described  by  the  other ;  and  this  movement  can  only  be 
backwards,  since  all  the  fixed  points  lie  in  that  direction.  If  any  poste- 
rior part  of  the  muscle  were  advanced,  it  could  not  relax  the  zonule,  since 
this  structure  is  only  attached  to  the  muscle  along  its  lenticular  head ;  and 
as  the  movement  which  this  makes  is  backwards,  it  must  render  the  zonule 
in  front  of  it  more  tense,  and  thereby  diminish  the  convexity  of  the  lens. 
It  seems  to  me  that  nothing  can  invalidate  this  conclusion,  unless  it  be 
shown  that  there  does  exist  a  circular  mass  of  fibres  whose  centric  contrac- 
tion diminishes  its  lumen.  But  we  know  that  in  high  degrees  of  M  such 
fibres  are  rare ;  in  some  eyes  they  are  entirely  absent ;  and  are  never 
found  in  any  of  the  domestic  animals  except  the  pig,  and  in  that  one  it 
exists  only  in  the  posterior  part  of  the  muscle.    As  accommodation  takes 


356         De  Rosset,  Action  of  Muscle  of  Accommodation.  [Oct. 

place  in  all  of  these  without  the  intervention  of  circular  fibres,  why 
should  they  be  invoked  in  any  instance  ?  The  probable  function  of  the 
anastomosing  fibres  has  already  been  explained. 

The  two  anterior  heads  of  the  muscle  respond  to  the  same  nervous  im- 
pulses, whether  volitional  or  reflex,  contracting  or  relaxing  synchronously. 
The  outer  head  holds  the  muscle  firmly  in  contact  with  the  sclerotic,  and 
prevents  the  excessive  dragging  back  of  the  muscle  and  associated  struc- 
tures, which  would  inevitably  follow  if  there  were  not  a  fixed  point  at  the 
corneo-scleral  line.  The  inner  head,  which,  it  will  now  be  seen,  is  the 
only  essential  agent  in  accommodation,  actuates  the  lens  through  the  me- 
dium of  the  zonule.  If  the  outer  head  did  in  effect  approximate  slightly 
the  two  poles  of  the  eye,  and  so  relax  the  zonule,  this  relaxation  would  be 
more  than  neutralized  by  the  greater  backward  movement  described  by 
the  inner  head.  So  that  under  no  exigency  of  the  hypothesis  is  it  possible 
to  conceive  of  the  zonule  being  relaxed  by  contraction  of  the  ciliary  mus- 
cle. Besides,  the  anomaly  of  such  an  effect  forbids  its  assumption,  and 
would  render  the  idea  tenable  only  upon  actual  demonstration  of  its  truth. 

Let  us  now  see  what  this  exposition  has  led  us  to.  Acknowledging  the 
greater  convexity  of  the  lens  in  near  vision,  and  its  less  convexity  in 
remote  vision,  I  hold  that  the  elastic  power  of  the  lens  is  in  opposing  rela- 
tion to  the  contractile  power  of  the  ciliary  muscle,  and  that  when  there  is 
complete  muscular  relaxation  the  lens  is  thickened,  ad  maximum,  for  the 
nearest  possible  adjustment,  and,  contrariwise,  when  the  muscle  is  in  its 
state  of  greatest  possible  contraction  the  elasticity  is  overcome,  and  the 
adjustment  is  for  the  remotest  point.  This  implies  that  accommodation 
for  a  distance  is  an  active  product,  while  that  for  near  points  is  passive,  or 
due  to  resiliency  only,  a  fact  which  I  shall  endeavour  to  sustain  by  fur- 
ther argument  from  the  epi -phenomena,  when  we  come  to  consider  Don- 
ders'  ground  for  believing  the  contrary.  This  view  also,  it  may  be  said, 
implies  that  the  eye  is  in  a  state  of  rest  when  accommodated  for  near 
vision,  and  active  when  adjusted  for  remote  points — circumstances  which 
the  subjective  phenomena  may  seem  to  invalidate.  But  when  we  come  to 
analyze  Donders'  inferences  from  the  subjective  phenomena  of  near  vision, 
I  shall  show  that  these  are  not  referable  to  the  ciliary  muscle ;  and  that 
the  ciliary  muscle,  in  addition  to  its  homogeneous  relations  to  the  sphincter 
muscles,  has  many  analogies  with  them,  and  like  them,  when  uninfluenced 
by  the  will  or  reflex  causes,  is  normally  in  a  state  of  partial  contraction, 
to  be  in  reality  taken  as  its  state  of  rest.  Thus  we  find,  when  the  eyes  are 
not  actively  and  purposively  employed,  they  are  converged  and  accommo- 
dated for  a  point  about  eight  feet  distant,  called  the  mesoropter,  which, 
ipso  facto,  must  be  their  point  of  equilibrium  or  rest. 

The  ciliary  muscle  is  a  very  feeble  muscle,  as  may  be  inferred  from  its 
extreme  tenuity,  but  what  its  dynamic  power  is  I  do  not  know,  and  can 
conceive  of  no  means  of  measuring  it,  for  the  lens,  upon  its  removal  from 


1878.]     De  Rosset,  Action  of  Muscle  of  Accommodation.  357 

the  body,  loses  its  elasticity  so  speedily  that  it  is  impossible  to  estimate  by 
experiment  the  equivalent  in  units  of  weight  which  the  muscle  must  possess 
in  order  to  overcome  this  elasticity.  The  muscle  has,  perhaps  nothing  else 
to  do  except  to  overcome  the  convexity  of  the  lens,  and  perhaps  to  exercise 
pressure  in  relation  to  secretion  and  absorption.  I  am  quite  sure  it  is  too 
feeble  to  have  any  effect  upon  the  dense  sclerotic  coat,  in  the  way  of  pro- 
ducing staphyloma,  unless  an  unimportant  predisposing  one,  as  in  myopes, 
in  whom,  according  to  this  theory,  the  muscle,  in  order  to  maintain  a 
comparative  flatness  of  the  lens  (so  as  to  neutralize  the  refractive  error)  is 
in  an  habitual  state  of  greater  or  less  contraction.  Of  the  possible  relation 
of  this  pressure  to  some  forms  of  glaucoma,  suggested  by  this  study,  I 
shall  say  a  few  words  later.  The  active  agents  in  the  production  of 
staphyloma  are  the  periglobar  muscles  in  the  powerful  pressure  which 
they  maintain  upon  the  bulb  in  close  convergence,  particularly  in  cases  of 
disturbed  coordination  when  antagonistic  muscles  are  simultaneously  tense. 

It  will  be  noted,  and  perhaps  with  surprise,  that  this  theory  is  just  the 
reverse  of  the  Helmholtz  theory,  as  stated  by  Donders.1  He  holds  that 
the  zonule  is  relaxed  when  the  ciliary  muscle  is  contracted,  but  evidently 
wishing  to  avoid  the  absurdity  which  the  converse  would  involve,  he  very 
ingeniously  relegates  the  tension  of  the  zonule  to  neighbouring  elastic 
parts,  a  proposition  hardly  more  tenable,  because  the  zonule  is  attached  to, 
and  can  be  influenced  by,  no  other  neighbouring  part  except  the  lenticular 
head  of  the  ciliary  muscle. 

In  pursuance  of  the  plan  laid  down  early  in  the  course  of  this  paper,  our 
next  step  must  be  to  inquire  into  the  information  deducible  from  an 
analysis  of  the  subjective  phenomena  observed  in  accommodation.  These 
may  be  of  two  kinds  :  those  experienced  in  near  vision,  and  those  in  dis- 
tant vision,  although  Donders,  in  giving  his  reasons  for  maintaining  the 
Helmholtz  theory,  seems  to  ignore  the  latter  entirely.  I  am  quite  sure 
that  nothing  conclusive  is  to  be  drawn  from  a  consideration  of  subjec- 
tive phenomena,  and  it  is  to  be  regretted  that,  in  a  work2  so  uniformly 
careful  in  its  postulates,  and  logical  in  its  deductions,  so  much  stress  should 
have  been  laid  upon  them. 

The  subjective  phenomena  (fatigue,  strain,  pain,  etc.)  associated  with 
the  act  of  vision  at  near  points  proceeds  mainly,  if  not  wholly,  from  the 
forcible  contraction,  and  long  pressure  of  the  internal  recti  muscles,  the 
sensations  being  equivalent  in  every  respect  to  those  which  result  from 
overtaxing,  by  powerful  or  long-sustained  effort,  any  of  the  voluntary 
muscles  of  the  body.  A  simple  experiment  suffices  to  demonstrate  the 
truth  of  this  proposition.  If  prisms  of  4  or  5  degrees  be  held  with  bases 
inwards  before  a  pair  of  emmetropic  eyes,  the  individual,  provided  the  so- 
called  positive  part  of  his  relative  range  of  accommodation  is  normal,  will 


1  Accom.  &  Refract.    New  Syd.  Soc.  Trans,  p.  20  et  seq. 


3  Ibid. 


358         De  Rosset,  Action  of  Muscle  of  Accommodation.  [Oct. 


be  able  to  read,  without  any  of  the  subjective  phenomena  of  close  vision, 
even  when  the  print  is  held  almost  at  his  near  point.  This  is  because  the 
eye-ball  is  relieved  of  the  pressure  ordinarily  exerted  upon  it  by  the  peri- 
globar  muscles  in  accommodation  for  that  distance;  and  because  the  action 
of  the  ciliary  muscle  is  insufficient,  or,  rather,  not  of  a  kind  to  produce 
the  phenomena.  But  if  we  admit,  for  the  moment,  that  a  part  of  the 
subjective  phenomena  occurring  in  near  vision  is  due  to  the  fatigue  of 
the  ciliary  muscle,  what  would  we  have  left  to  explain  the  well-known 
sense  of  fatigue  and  strain  which  every  one  admits  is  associated  with 
long  gazing  into  great  distances'?  Under  these  circumstances  none 
of  the  periglobar  muscles  are  in  a  state  of  contraction,  none  of  them  are 
pressing  upon  the  globe;  and,  therefore,  if  we  admit,  as  the  Helmholtz 
theory  alleges,  that  the  ciliary  muscle  is  also  relaxed,  nothing  would 
remain  to  produce  the  subjective  associations  of  distant  vision.  The 
fatigue,  etc.,  of  close  vision  is  not  due  to  accommodation,  but  to  conver- 
gence; and  I  cannot  fail  to  recognize  that  the  sensations  accompanying 
distant  vision,  so  unlike  the  others,  are  the  outcome  of  the  exercise  of  the 
feeble  unstriped  ciliary  muscle.  And  so  we  have  the  subjective  pheno- 
mena of  both  states  of  accommodation  fully  explained,  and  thereby  see 
that  Donders'  ground  for  maintaining  the  activity  of  so-called  positive  ac- 
commodation only  is  insufficient  and  erroneous.  Moreover,  Donders  says1 
that  "all  voluntary  movements  require  the  intervention  of  muscular  ele- 
ments," but,  in  strange  contradiction,  denies  any  muscular  element  in  the 
adjustment  towards  go.  Certainly  he  must  regard  this  act  of  the  accom- 
modation as  much  an  operation  of  the  will  as  is  the  other ! 

Probably  nothing  has  contributed  a  greater  obstacle  to  a  solution  of  the 
problem  of  accommodation  than  the  erroneous  views  which  have  prevailed 
respecting  the  action  of  mydriatics  and  myotics,  represented  respectively 
by  atropia  and  eserine.  Physiologists  have  differed  as  to  the  influence  of 
these  agents  upon  the  motor  centres  and  upon  muscular  fibre,  but  the 
weight  of  authority,  based  upon  experimental  and  clinical  observations,  is 
to-day  largely  in  favour  of  the  view  which  attributes  to  atropia  a  tetan- 
izing  effect  upon  the  muscular  system,  and  to  eserine  a  paralyzing  effect. 
Donders,  it  is  true,  considers  it  little  less  than  absurd  to  suppose  this,  but 
it  is  evident  that  the  Helmholtz  theory  has  driven  him  to  such  a  position. 

Dr.  H.  C.  Wood  has  shown  2  that  atropia  stimulates  the  frequency  of 
the  heart  and  increases  the  arterial  tension.  Harley  and  Meyron  show3 
that  belladonna  (atropia)  stimulates  the  sympathetic,  and  that  small  doses 
induce  contraction  of  the  arteries — evidently  tetanizing  effects. 

M.  Lemattre  and  Wharton  Jones4  asserted  that  atropia  does  not  dilate 
the  irides  of  pigeons,  because  there  are  no  radial  fibres;  from  which  we 


1  Op.  cit.,  p.  20. 

3  Lancet,  1874,  No.  1,  p.  903. 


2  Am.  Journ.  Med.  Sci.,  vol.  lxv.  p.  333. 
4  Lancet,  1857,  vol.  i.  p.  59. 


1878.]     De  Rosset,  Action  of  Muscle  of  Accommodation.  359 


may  infer  that  when  dilatation  does  take  place  it  must  be  through  a  stimu- 
lating action  on  these  fibres,  and  that  a  paralyzing  effect  upon  the  circular 
fibres  is  not  of  itself  sufficient  to  enlarge  the  pupil.  In  reference  to  this 
anatomical  peculiarity,  however,  Iwanoff  and  Rollett1  demonstrate  in  a 
beautifully  illustrated  paper  that  it  does  not  exist,  but  that  pigeons  do  pos- 
sess radiating  fibres  in  their  irides.  So  that  nothing  definite  is  to  be 
deduced  from  the  experiments  upon  these  birds,  except  that,  like  rabbits, 
they  are  little  susceptible  to  the  influence  of  belladonna.  The  conclusions 
of  these  two  last-named  authors  are  confirmed  by  Max  Schultze,2  who  is 
in  turn  corroborated  by  Johann  Diegel. 

Hensen  and  Yoelckers,  in  experiments  conducted  in  Kiel  in  1868,  laid 
bare  the  ciliary  muscle  by  removing  sections  of  the  sclerotic  in  the  ciliary 
region,  when  upon  irritating  (electrically)  the  nerves,  and  applying  atropia 
to  them,  the  muscle  sunk  and  the  choroid  arched  forwards.  It  is  per- 
fectly clear  that  this  effect  could  have  ensued  only  upon  contraction  of  the 
muscle  ;  for,  as  this  springs  into  a  tense  state  in  the  tendency  to  form  the 
arc  to  the  sclerotic  chord  (as  described),  it  would  withdraw  slightly,  and 
so  arch  the  choroid. 

In  reference  to  the  clinical  observations  of  atropia,  I  need  only  allude 
briefly  to  its  well-known  action  in  increasing  peristalsis ;  to  its  use  in 
night-sweats;  and  to  its  tendency  to  induce  dryness  Of  the  pharynx,  and 
to  diminish  glandular  action  and  bronchial  secretion ;  to  its  marked  power 
in  giving  tone  to  the  sphincter  vesicae,  in  the  incontinence  of  urine  in 
children — all  due  to  its  tetanizing  influence  upon  muscular  fibre  through 
the  sympathetic. 

In  a  wTord,  whichever  way  we  turn  we  fail  to  find  primary  paralysis  of 
any  muscle  induced  by  atropia,  and  I  would  therefore  ask,  why  should  an 
exception  be  made  as  to  the  ciliary  muscle?  Unfortunately,  facts  have 
been  here  perverted  to  conform  to  theory,  and  probably  have  aided  in  the 
perpetuation  of  error.  I  admit  that  nothing  absolute  is  shown  with  respect 
to  the  action  of  this  muscle  under  atropia,  because  of  the  insuperable  obsta- 
cles to  successful  experiments  with  it  on  the  human  eye  ;  but  from  analogy 
we  have  the  best  reasons  to  infer  that  atropia  causes  it  to  contract,  a  fact 
that  mast  invalidate  the  Helmholtz  theory  in  its  essence,  and  give  addi- 
tional probability  to  the  theory  which  this  paper  has  advanced  upon 
anatomical  grounds. 

I  must  not  forget  to  mention  the  experiments  of  Messrs.  Tweedy, 
Ringer,  and  others  with  the  Duboisia  Myoporoides,  a  plant  so  closely  resem- 
bling in  its  effects  belladonna,  that  its  active  principle  was  at  first  supposed 
to  be  identical  with  atropia.  It  produces  general  tetanus  ;  it  tetanizes 
smooth  muscles  ;  it  neutralizes  the  paralyzing  effect  of  muscarine  ;  and  it 

1  Archiv  fur  OpMhal.,  vol.  xv.  Abth.  1. 

2  Archiv  fiir  Mikros.  Anat.,  vol.  yi.  Heft.  1, 1870. 


360         De  Rosset,  Action  of  Muscle*of  Accommodation.  [Oct. 

affects  the  pupil  and  the  accommodation  precisely  as  does  atropia.  It  has 
no  paralyzing  effects.  What  we  say  of  it  is,  without  doubt,  applicable  to 
its  congener — atropia. 

The  physiological  experiments  with  Calabar  bean  (eserine)  are  not  very 
abundantly  recorded.  Hensen  and  Voelckers  noticed  that  it  caused  decided 
advance  of  the  ciliary  processes,  while  atropia  caused  equally  decided  re- 
traction. Of  course  the  supporters  of  the  old  theory  may  see  nothing 
conclusive  in  this  ;  but  to  me,  coupled  as  it  is  with  the  anatomical  arrange- 
ment of  the  ciliary  muscle,  and  with  the  conceded  paralyzing  effect  of 
Calabar  upon  muscles  generally,  it  becomes  a  most  significant  fact. 

The  efficacy  of  Calabar  in  tetanoid  affections  has  been  very  conclusively 
pointed  out  by  many  writers  in  this  country,  and  by  Mr.  Thorburn 
Patterson  and  others  in  England.  In  fact,  it  is  so  generally  known 
that  no  further  allusion  need  be  made  to  it.  There  is  no  necessity  for 
supposing  that  it  acts  upon  the  ciliary  muscle  in  a  way  different  from 
that  which  has  been  demonstrated  for  other  muscles,  and  I  have  failed  to 
find  a  single  instance  of  its  tetanizing  effect.  This  is  a  difficulty  which 
the  Helmholtz  theory  cannot  overcome,  whereas  the  phenomena  of  Calabar 
present  only  harmonies  with  the  theory  here  offered.  I  would  allude  also 
to  the  experiments  of  Galezowski  with  pilocarpine — a  substance  of  which 
the  paralyzing  effect  is  well  known.  It  affects  the  eye  precisely  as  does 
eserine. 

I  will  recall  what  the  Helmholtz  theory  says  of  atropia  and  eserine : 
Atropia  adjusts  the  vision  for  distant  points,  because  it  paralyzes  the 
ciliary  muscle,  and  eserine  adjusts  it  for  near  vision  because  it  tetanizes 
the  same  muscle  :  effects,  it  is  to  be  noted,  totally  dissimilar  to,  and 
quite  the  reverse  of,  those  which  these  agents  are  known  to  exert  in  every 
other  part  of  the  body,  however  analogous  in  its  histological  and  physio- 
logical features  to  the  ciliary  muscle.  On  the  contrary,  the  theory  of  this 
paper,  in  order  to  account  for  the  physical  phenomena  which  atropia  and 
eserine  elicit,  requires  them  to  exert  the  same  effect  upon  the  ciliary  muscle 
that  they  exert  elsewhere  in  the  economy. 

This  inquiry  might  with  confidence  be  allowed  to  rest  here,  but  the 
strong  claim  to  support  which  is  made  for  the  Helmholtz  theory,  upon 
grounds  educed  from  the  phenomena  of  intra-cranial  and  nerve  lesions, 
requires  that  we  shall  examine  into  the  true  inferences  to  be  drawn  from 
them.  It  cannot  be  denied  that  some  cases  of  what  are  now  called  paraly- 
sis and  spasm  do  apparently  harmonize  with  the  Helmholtz  theory,  but 
when  we  consider  how  complex  neurological  questions  are,  particularly 
where  an  uncertainty  prevails  as  to  both  central  and  peripheric  organs,  as 
well  as  to  the  tracts  of  conduction  of  nerve  impulses,  and  the  modification 
which  these  undergo  by  anastomosis,  and  further  ganglionic  elaboration, 
it  will  be  readily  seen  how  liable  any  general  conclusions  from  them  are  to 
be  erroneous.    Although  Ave  may  have  a  mass  of  positive  facts  in  favor  ot 


1878.]     De  Rosset,  Action  of  Muscle  of  Accommodation.  361 

a  given  proposition,  yet  if  we  discover  a  single  fact  equally  positive  which 
renders  it  improbable,  the  chances  are  that  conclusions  from  the  first  will 
prove  erroneous.  Even  experimental  physiology,  which  is  of  such  great 
consequence  in  enabling  us  to  trace  the  relations  of  cause  and  effect,  has 
contributed  nothing  absolutely  definite  respecting  the  motor  nerves  of 
the  intra-ocular  muscle;  so  that  physiologists,  in  attempts  to  unravel  this 
problem,  have  been  obliged  to  reason  from  effect  to  cause — from  phenom- 
enon to  lesion — a  process  which  involves  hypotheses  at  every  step,  and  is 
little  to  be  relied  on  to  establish  principles. 

As  yet  little  is  known  by  demonstration  of  the  nerve  tract  through 
which  motor  impulses  come  to  the  ciliary  muscle,  or  of  the  central  seat 
whence  they  originate,  or  of  the  modifications  they  undergo  by  associa- 
tion, or  through  special  ganglionic  influence.  It  is  known  that  the  third, 
fourth,  and  sixth  nerves  are  motor  tracts  for  the  periglobar  and  other 
extra-ocular  muscles  ;  that  these  in  their  course  communicate  freely  with 
other  nerves,  conspicuously  the  fifth  and  sympathetic,  but  for  what  purpose 
we  are  ignorant :  whether  it  be  for  the  interchange  of  their  respective  in- 
fluences, or  to  establish  co-ordinate  associations,  direct  or  inverse,  or  to 
provide  for  reflex  conduction  and  responses,  is  almost  wholly  a  matter  of 
conjecture.  Injuries  within  the  cranium,  whether  of  coarse  disease,  acci- 
dental, or  purposive,  for  experimentation,  do  not  by  any  means  evolve 
uniform  results,  although  they  may  be  similarly  located.  Injury  or  disease 
of  the  Gasserian  and  lenticular  ganglia  give  different  results  in  different 
cases,  probably  from  communication  of  the  disease  or  injury  to  contiguous 
nerve  fibres. 

The  third  and  fifth1  nerve  and  the  sympathetic  may  each  contribute 
something  towards  the  motor  supply  of  the  ciliary  muscle,  as  each  con- 
tributes branches  to  the  ciliary  ganglion  ;  but  if  this  ganglion  be  destroyed 
the  pupil  is  neither  markedly  dilated  nor  contracted,  and  the  accommoda- 
tion is  usually  adjusted  for  go  ,  but  not  always.  Whether  these  uncertain 
effects  are  referable  to  the  sympathetic  or  to  the  third  nerve  element  in 
the  ganglion  is  not  known.  If  the  third  nerve  be  divided  posteriorly  to  the 
ciliary  ganglion,  usually  paralysis  of  superior,  inferior,  and  internal  recti 
and  inferior  oblique  follows,  but  not  always.  Sections  of  the  sympathetic 
in  the  neck  produce  often  an  adjustment  for  near  points,  with  myosis  ;  and 
Reuling's  case,  reported  in  Knapp's  Archives  for  Ophthal.  and  Otol., 
indicates  that  injury  or  disease  in  the  cervical  region  may  produce  the 
same  effect.  Why  the  result  is  not  uniform  we  cannot  say,  but  it  is  pos- 
sible that  it  may  proceed  from  one  or  two  circumstances :  first,  certain 
fibres  of  the  sympathetic  which  influence  the  ciliary  muscle  may  escape  ; 
for,  according  to  Vulpian,  all  the  sympathetic  fibres  do  not  pass  through 
the  first  cervical  ganglion,  or  through  the  portion  of  the  trunk  above  that ; 

1  I  say  fifth:  see  Hensen  and  Voelcker's  experiments,  Graefe  Archiv.,  Bd.  xxiv. 
Abth.  1. 


362         De  Rosset,  Action  of  Muscle  of  Accommodation.  [Oct. 

and  second,  there  may  be  anomalies  in  the  course  or  distribution,  pro- 
ducing unexpected  effects,  just  as  paralyses  are  often  found  on  the  same 
side  as  that  upon  which  a  cerebral  injury  has  happened,  and  which  are 
now  believed  to  be  due  to  anomalies  in  the  course  of  the  pyramidal  fibres, 
which,  instead  of  crossing  to  the  posterior  lateral  columns  of  the  spinal 
cord  on  the  opposite  side,  continue  directly  into  those  of  the  same  side. 

Hensen  and  Voelcker's  latest  experiments1  to  determine  which  is  the 
nerve  of  accommodation  do  not  seem  to  yield  any  satisfactory  informa- 
tion, and,  as  I  see  no  promise  of  benefit  in  prolonging  this  paper  into  an 
analysis  of  them,  I  would  simply  express  my  conviction  that  they  are  very 
contradictory,  and  leave  the  question  precisely  where  it  stood  before.  For 
instance,  irritation  of  the  root  of  the  oculo-motor  nerve,  and  of*  the  trunk  of 
the  nerve  in  the  orbit,  gave  no  results  in  several  of  the  experiments;  but 
experiments  directly  upon  the  ciliary  ganglion  and  ciliary  nerves,  and  even 
upon  the  fifth  nerve,  whether  by  section  or  irritation,  produced  profound 
effects.  The  nerve  of  accommodation  therefore  must  be  left  for  the  present 
to  hypothesis  founded  upon  the  anatomy  of  the  ciliary  muscle,  and  upon 
the  observation  of  the  effects  of  mydriatics  and  myotics.  And  I  conceive 
that  it  is  not  of  vital  importance  to  the  physiological  problem  that  this 
question  should  be  answered  here.  My  own  hypothesis  in  respect  to  this 
(upon  which,  however,  I  lay  no  stress)  is,  to  the  effect  that  the  sympa- 
thetic nerve  determines  the  contraction  of  the  ciliary  muscle,  perhaps 
through  fibres  which  come  from  the  motor  centre  of  accommodation.  It 
conveys  to  the  muscle  the  volitional  impulse,  as  well  as  the  reflex  and  co- 
ordinating stimulus  which  secures  the  correspondence  it  is  known  to  have 
with  other  muscular  movements.  An  excitation  of  the  oculo-motor  may 
determine  an  apparent  paresis  of  the  sympathetic  ;  while  a  paralysis  of  the 
oculo-motor  may  give  a  dominant  effect  to  the  function  of  that  nerve  ;  and 
the  converse  of  both  these  propositions  may  be  true.  So  that  what  is  now 
said  to  be  paralysis  of  the  ciliary  muscle,  and  due  to  the  pressure  upon 
the  third  nerve,  with  impairment  of  its  neurility,  is  interpreted  by  the 
terms  of  my  theory  to  be  a  spasm,  due  to  dominant  effect  of  the  sympa- 
thetic or  some  other  nerve  centre.  It  is  not  an  uncommon  thing  to  witness 
depression  of  one  function  accompanied  by  exaltation  of  another  in  some 
way  correlated  with  it.  And  according  to  Brown-Sequard  the  disturbance 
of  any  portion  of  the  brain,  from  causes  centric  or  peripheric,  may  deter- 
mine in  other  portions  disturbances  of  a  similar  or  opposite  nature  ; — that 
is,  that  circumstances  which  induce  paralysis  of  one  nerve,  may  indirectly 
exalt  the  neurility  of  another.  Therefore,  if  a  pathological  process  para- 
lyzes any  one  or  more  of  the  periglobar  muscles,  there  may  be  a  simulta- 
neous spasm  of  the  ciliary  muscle.  I  shall  not  attempt  to  explain  how  this 
takes  place,  but  only  note  the  possibility. 


1  Graefe's  Archiv,  Bd.  XXXIV.  Abth.  1. 


1878.]     De  Eosset,  Action  of  Muscle  of  Accommodation. 


363 


The  cases  of  so-called  spasmodic  myopia  (of  idiopathic  origin)  are  very 
rare.  M.  Charcot1  cites  one  of  a  woman  suffering  with  hemi-ana?sthesia, 
myosis  and  myopia  of  0.75  dioptrics  (although  she  was  hypermetropic), 
which  two  latter  conditions  atropia  only  momentarily  affected.  The 
myosis  and  myopia  were,  of  course,  attributed  to  spasm.  Our  theory 
looks  upon  them  as  due  to  reflex  paralysis  (through  impairment  of  neurility 
of  certain  fibres  in  the  sympathetic),  and  this  would  bring  them  in  conso- 
nance with  the  other  symptom,  hemi-anoesthesia,  which  no  one  denies  is  a 
paralysis. 

Galezowski3  has  seen  a  case  of  acquired  (so-called  spasmodic)  myopia 
from  syphilis ;  this  it  seems  to  me,  from  the  effect  which  syphilis  gener- 
ally has  upon  the  accommodation,  would  locate  the  lesion  out  of  the  oculo- 
motor tract,  and  indicate  that  the  portion  of  the  sympathetic  influencing 
the  accommodation  was  affected,  i.  e.,  rendered  paretic  ;  for  the  third  nerve 
was  certainly  not  affected,  if  we  may  judge  from  the  integrity  of  the  extra- 
ocular muscles.  I  need  scarcely  remark  that  I  regard  this  condition  not 
as  one  of  spasm,  but  as  a  paralysis  of  the  ciliary  muscle,  from  which  the 
elasticity  of  tlje  lens  was  allowed  free  play,  producing  the  myopia  ;  and,  in 
effect,  we  find  Xagel3  and  others  making  use  of  hypodermic  injections  of 
strychnia  with  marked  benefit  in  such  cases  ;  but  they  did  not  recognize 
that  the  condition  was  one  of  paralysis  although  so  much  benefited  by 
strychnia.  I  am  able  to  cite  from  my  own  records  several  cases  bearing 
upon  this  point. 

A  young  girl,  aged  14.  who  had  never  menstruated,  and  possessed  few 
signs  of  puberty,  came  with  a  widely  dilated  pupil.  Had  had  headache, 
and  a  "  white  veil"  over  the  left  eye  for  12  hours.  The  headache  Avas 
confined  chiefly  to  the  supra-orbital  branch  of  the  left  trigeminus.  The 
accommodation  was  for  ac.  and  V  =  |g.  Ophthalmoscopic  and  visual  fields 
normal,  and  she  had  M  as  determined  by  the  ophthalmoscope  and  test- 
types.  Required  convex  T\  to  read  at  12",  and  concave  for  Sn.  xx  at 
20'.  One  drop  of  a  one  per  cent,  solution  of  eserine  (it  had  been  prepared 
3  months)  produced  complete  myosis  in  15  minutes.  She  then  required 
concave      for  Sn.  xxx  at  20',  and  read  at  8"  without  glasses. 

The  effect  of  the  eserine  did  not  wholly  pass  away  for  48  hours,  and  the 
morbid  symptoms  did  not  return.  I  am  constrained  to  regard  the  case  as 
one  of  reflex  spasm  of  the  ciliary  muscle,  from  irritation  of  the  fifth  nerve. 
The  Helmholtz  theory  would  regard  it  as  one  of  complete  paralysis,  but 
paralysis  limited  to  a  single  muscle  is  almost  unknown  in  healthy  subjects, 
whereas  reflex  spasm  is  a  common  concomitant  of  pain  and  peripheral 
irritation.    The  speedy  relief  obtained  from  eserine. also  implies  spasm. 

I  shall  not  attack  the  whole  subject  of  paralysis  and  spasm.  I  admit 
that  some  of  their  phenomena  are  quite  unintelligible  upon  any  hypothesis, 
but  chiefly  so  when  it  is  known  that  the  lesion  is  sufficiently  extensive  to 


1  Prog.  Med.  Jan.  19, 1878. 

8  Klin.  Monatsblat.  1871,  p.  391. 


2  Idem. 


364 


De  Rosset,  Action  of  Muscle  of  Accommodation. 


render  the  factors  which  produce  the  phenomena  both  numerous  and 
complicated.  The  paralysis  of  diphtheria,  for  instance,  is  wholly  a  mys- 
tery, and  until  that  is  solved  we  cannot  know  with  certainty  why  mydri- 
asis and  adjustment  for  r  should  exist,  although  the  hypothesis  advanced, 
of  a  tetanizing  effect  or  dominant  influence  of  the  sympathetic,  would 
account  for  it,  and  it  is,  not  forbidden  by  any  fact  or  physiological  reason. 

The  range  which  this  inquiry  might  take  is  very  great,  and  cannot  be 
followed  to  its  limits.  There  are  many  aspects  of  it  which  might  form 
special  subjects  for  discussion.  I  must  say,  however,  that  the  more 
thoroughly  I  consider  it  the  more  probable  does  this  new  theory  appear, 
and  nowhere  yet  have  I  encountered  facts  which  seriously  threaten  to 
overturn  the  conclusions. 

Before  closing,  in  order  to  clear  away  the  confusion  which  grows  out  of 
the  use  of  expressions  to  denote  conditions  the  reverse  of  what  they  have 
denoted  in  the  past,  I  desire  to  consider  briefly  the  relation  of  this  new 
theory  to  hypermetropia  and  myopia. 

First,  as  to  latent  hypermetropia,  it  is  commonly  held  that  the  latency 
is  due  to  a  tonic  spasm,  whereas  our  theory  holds  it  to  be  a  quantitative 
relaxation  of  the  ciliary  muscle.  It  must  be  remembered  that  only  that 
portion  of  the  entire  range  of  the  muscular  play  sufficient  to  neutralize  the 
error  of  refraction  is  affected,  the  remaining  portion  of  the  range  being 
unimpaired.  But  spasm  rarely  involves  a  muscle  in  that  way.  impairing 
a  part  of  its  range,  and  leaving  the  remainder  unimpaired.  Its  effect  is 
to  limit  action,  and  to  induce  unsteady  and  more  violent  contraction 
throughout  the  whole  range.  If  it  were  spasm,  i.  e.,  a  tonic  exercise  of 
the  muscular  irritability,  we  should  not  be  able,  as  we  often  are,  to  remove 
it  by  suitable  convex  lenses  and  prisms. 

Moreover,  if  this  vital  contraction  of  the  sarcous  elements  of  a  muscle 
should  become  permanent  (as  is  alleged  in  HI),  by  a  well  recognized  his- 
tological law  we  should  have  a  wasting  of  them,  and  an  increase  in  the 
myolemma,  or  elastic  element,  which  we  know  does  not  as  a  rule  occur  in 
H.  It  is  only  active  intermitting  exercise  of  muscular  fibrillar  that  leads 
to  their  hypertrophy  (as  in  the  oft-cited  case  of  the  blacksmith's  arm). 

The  ciliary  muscle  is  correlated  in  its  movements  with  the  internal  and 
external  recti  muscles — inversely  with  the  internal  rectus,  and  directly 
in  a  limited  way  with  the  external.  When  these  coordinations  are  dis- 
turbed, as  they  are  in  hypermetropia,  there  will  follow  fatigue  (asthenopic 
symptoms),  because  the  two  opposing  recti  muscles  are  brought  into  play 
simultaneously  to  make  the  convergence  conform  to  the  accommodation. 
This  forcible  action  compresses  the  globe,  which,  with  the  sustained  ten- 
sion of  the  two  muscles,  is  quite  sufficient  to  account  for  the  asthenopia 
without  charging  the  comparatively  relaxed  ciliary  muscle  with  any  of  it. 

No  form  of  asthenopia  is  more  immediately  produced  than  that  which 
accompanies  the  act  of  looking  strongly  upwards,  even  with  accommoda- 


1878.]     De  Rosset,  Action  of  Muscle  of  Accommodation.  365 


tion  for  distance ;  and  the  same  may  be  said  of  looking  strongly  down- 
wards. In  both  of  these  acts  several  muscles  are  implicated,  and  their 
location  is  such  as  to  compress  the  globe  when  they  thus  contract  synchro- 
nously. 

It  will  also  be  found,  after  the  ciliary  muscle  has  been  thoroughly 
atropinized,  that  a  prolonged  attempt  at  reading,  say  at  6  or  8  inches,  even 
with  suitable  convex  lenses,  will  entail  asthenopic  symptoms,  obviously 
due  only  to  pressure,  and  antagonism  of  external  rectus.  If  the  asthen- 
opia of  hyperopes  proceeded  from  a  forcible  tension  of  the  ciliary  muscle, 
the  use  of  atropia  would  likewise  produce  those  symptoms,  which,  however, 
it  does  not. 

I  would  call  attention  before  closing  to  the  very  common  effect  of  atropia, 
when  vigorously  applied,  of  changing  the  refraction  so  as  to  imply  that  an 
HI  had  existed  even  as  high  as  1  dioptric,  in  eyes  which  every  other  test 
had  shown  to  be  emmetropic.  So  common,  indeed,  is  this,  that  many 
ophthalmologists  have  supposed  an  HI  in  every  eye. 

As  all  hypermetropia  is  the  result  of  a  short  optic  axis,  of  course  this 
suspected  latency  is  said  to  proceed  from  a  supposed  remnant  of  tension  in 
the  ciliary  muscle  ;  which  until  removed  by  atropia  prevents  the  lens  from 
attaining  its  maximum  thinness.  The  true  explanation  of  this  apparent 
HI  is  that  after  full  adjustment  for  r,  the  instillation  of  strong  atropia  tetan- 
izes,  and  still  further  shortens  the  ciliary  muscle,  and  so,  by  the  traction 
exerted  through  the  zonule,  renders  the  lens  yet  thinner.  I  have  fre- 
quently noted  this  effect  not  only  in  emmetropic  .but  also  in  myopic  eyes  ; 
for  instance,  a  myopia  of  2V  has  been  reduced  by  the  vigorous  use  of  atro- 
pia to  and  even  3L.  The  effect  is  best  shown  in  young  subjects.  This 
fact  is  an  enigma  to  the  Helmholtz  theory. 

There  seems  little  reason  to  doubt  that  atropia  causes  an  increased  ten- 
sion within  the  eye,  and  if  so  no  more  satisfactory  explanation  can  be 
given  of  it  than  is  offered  by  this  view  of  its  tetanizing  effect  upon  the 
ciliary  muscle ;  and,  indeed,  it  is  uncertain  that  its  alleged  action  in  dilat- 
ing the  small  vessels  (which,  by  the  way,  cannot  be  made  out  with  the 
ophthalmoscope)  would  or  could  elevate  the  tension.  It  is  true  that  some 
observers,  notably  Adamiik  and  Grundhagen,  hold  that  atropia  diminishes 
the  intra-ocular  pressure,  but  v.  Graefe,  Wharton  Jones,  and  Hart  state 
that  this  is  an  error,  and  that  the  pressure  is  decidedly  increased  by  it. 
Panas  has  endeavoured  to  reconcile  the  differences  by  stating  that  the 
changes  in  tension  depend  upon  the  pathological  state.  But  our  means 
for  registering  the  tension  are  very  crude,  and  are  not  trustworthy.  Cer- 
tain it  is,  latterly  it  has  been  shown  that  the  use  of  atropia  tends  to  aggra- 
vate the  pain  arising  from  the  increased  tension  of  glaucomatous  states. 

It  seems  to  me  that  this  view  of  the  action  of  atropia  furnishes  a  contri- 
bution to  the  very  interesting  inquiry  into  the  etiology  of  glaucoma  and 
increased  tension,  which  has  occupied  so  much  attention  during  the  past 


366         De  Rosset,  Action  of  Muscle  of  Accommodation. 


year.  I  think  there  is  a  uniform  assent  to  the  proposition  that  both  glau- 
coma and  increased  tension  are  due  to  derangements  of  the  drainage 
system  of  the  eye,  and  particularly  to  obstruction  of  the  canal  of  Fontana, 
but  no  satisfactory  explanation  has  been  offered  of  the  cause  of  the  primary 
disturbances. 

Mr.  Brailey,-  Curator  of  the  Royal  London  Ophthalmic  Hospital,  has 
made1  valuable  contributions  to  the  subject  of  increased  tension.  He 
found  changes  in  the  ciliary  body,  of  a  nature  not  definitely  described.  In 
forty-nine  cases  there  was  atrophy  of  the  ciliary  body,  and  in  many  cases 
there  were  no  circular  fibres  at  all. 

Of  course  the  state  of  refraction  was  not  known  in  these  cases,  nor 
could  the  degeneration  of  the  ciliary  body  (if  it  were  not  a  normal  condi- 
tion) be  followed  step  by  step,  so  as  to  throw  some  light  on  the  progressive 
intra-ocular  changes  in  jrlaucoma. 

Dr.  Loring  has  also  made  dissections  of  the  ciliary  muscle,  and  reports 
that  he  found  the  muscular  tissue  greatly  atrophied  in  high  degrees  of 
myopia.  He,  of  course,  would  hold  this  condition  to  be  one  of  atrophy 
from  disuse.  It  must  be  remembered  that  in  myopia  there  is  always  a 
relative  deficiency  in  the  amount  of  muscle  in  the  ciliary  region,  for 
geometric  reasons,  as  has  been  shown.  Now  it  cannot  be  questioned  that 
a  muscle  tends  to  atrophy  from  disuse,  but  it  can  scarcely  be  alleged  that 
in  any  degree  of  myopia  there  exists  such  an  habitual  disuse  of  the  muscle 
as  would  lead  to  excessive  wasting ;  for  even  in  the  higher  expressions 
the  eye  is  (at  least  at  the  present  day)  armed  with  a  correcting  glass  which 
of  necessity  entails  accommodative  efforts. 

Moreover,  I  have  stated  that  in  myopia  the  ciliary  muscle  is  in  a  con- 
stant state  of  greater  or  less  tension,  and  this  very  condition,  in  typical 
cases,  is  sufficient  to  give  rise  to  the  atrophy  which  is  found.  Every 
muscle  is  composed  of  two  histological  elements — the  fibrillar,  or  sarcous 
element,  which  possesses  vital  contractility  ;  and  the  connective  tissue,  or 
myolemma,  which  is  also  contractile,  but  only  physically  so.  A  long- 
continued  vital  tension  of  a  muscle  tends  to  a  waste  of  its  sarcous  element, 
and  to  increase  of  the  myolemma,  and  thus  is  furnished  one  form  of 
atrophy.  The  myolemma  itself  is  able  to  keep  up  the  tension  by  virtue 
of  its  physical  elasticity,  and  the  muscle  undergoes  structural  shortening, 
sometimes  without  a  serious  loss  of  fibrillar. 

The  question  naturally  presents  itself,  as  to  whether  this  constant  con- 
traction of  the  ciliary  muscle  in  myopia  has  any  relation  to  forms  of 
amblyopia  and  to  increased  tension.  Can  it,  by  obstructing  the  return  of 
venous  blood,  tend  to  disturb  the  equilibrium  between  secretion  and  ab- 
sorption ?  Can  it  account  for  the  common  venous  pulse  of  myopia  ?  These 
questions  are  very  suggestive,  but  are  obviously  beyond  the  scope  of  this 


1  R.  L.  0.  H.  Reports,  vol.  ix.  p.  11,  1877. 


1878.]    Cutler,  Bradford,  Globular  Richness  of  the  Blood.  367 

paper.    When  careful  observation  discloses  the  causal  relations  of  the 
different  metropic  states  to  glaucoma  (if  any  exist),  we  shall  be  able  to 
enlarge  the  field  of  our  inquiry  into  the  physiology  of  accommodation. 
46  West  Thirty-sixth  Street,  July,  1878. 


Article  IV. 

Action  of  Phosphorus,  Alkalies,  and  of  Quinia  on  the  Globular 
Richness  of  the  Blood.  By  Elbridge  G.  Cutler,  M.D.,  and  Edward 
H.  Bradford,  M.D.,  of  Boston. 

The  following  few  observations  in  a  field  of  investigation  which  has 
hardly  been  worked  upon  may  be  of  interest,  supplementing  the  facts  pub- 
lished in  The  American  Journal  of  the  Medical  Sciences  for  Jan.  1878. 

Action  of  Phosphorus  on  Healthy  Subjects. — This  drug  is  recommended 
by  Dr.  Brunton1  as  useful  in  pernicious  anaemia.  It  has  been  used  also 
in  leucocythaemia.  The  following  figures  show  its  effect,  in  the  healthy 
subject,  upon  the  globular  richness  of  the  blood. 

The  number  of  globules  in  blood  taken  from  the  finger  was 
Red  corpuscles        .    •    .       .  3,311,984 
White  corpuscles     .        .        .  4,737 
Ratio  of  white  to  red       .       .      1  to  690 
Phosphorus  .001  gramme  was  given  three  times  a  day,  and  increased  gradu- 
ally to  .00G  gramme.    This  caused  diarrhoea  and  vomiting.    The  medicine  was 
omitted  for  three  days,  and  again  taken  in  dose  of  .001  gramme  ter  die.  Twenty- 
five  days  after  the  medicine  was  first  taken,  the  count  showed 
Red  corpuscles        .       .       .  2,789,240 
White  corpuscles     .       ,       .  6,431 
Ratio  1  to  433 

A  marked  decrease  in  the  red  and  an  increase  in  the  white  was  noticed. 
The  drug  was  not  well  borne,  and  caused  gastric  disturbance  even  when 
taken  in  the  smaller  doses.  This  was  also  the  case  when  the  drug  was 
administered  to  a  case  of  pernicious  anaemia.  The  gastric  disturbance 
caused  by  .001  gramme  phosphorus  given  three  times  a  day  (in  the  form 
of  sugar-coated  pill)  necessitated  in  four  or  five  days  the  discontinuance 
of  the  medicine.  There  was  no  improvement  in  the  general  symptoms. 
There  was  an  increase  in  the  globular  richness  after  the  medicine  had 
been  given  four  days,  but  as  diarrhoea  was  caused  by  the  phosphorus  the 
increase  in  the  globular  richness  could  not  be  considered  anything  more 
than  a  physiological  change. 

In  a  case  of  leucocythaemia  the  drug  caused  gastric  disturbance  and 
diarrhoea.  There  was  a  slight  increase  in  the  globular  richness  during 
the  exhibition  of  the  phosphorus  which  was  probably  due  to  the  diarrhoea. 


1  Practitioner,  1875. 


368    Cutler,  Bradford,  Globular  Richness  of  the  Blood.  [Oct. 

To  return  to  the  case  of  the  healthy  subject  who  took  phosphorus,  several 
weeks  after  discontinuing  the  drug  the  globular  richness  was 

Red  corpuscles  .  .  .  3,249,600 
White  corpuscles     .       .       .  5, 754 

Ratio  1  to  564 

Action  of  Alkalies  on  Healthy  Subjects  M.  Pupier3  reported  the  follow- 
ing experiment  as  a  proof  that  the  number  of  red  corpuscles  increases  under 
the  action  of  alkalies. 

A  dog  was  given  87  grms.  of  bicarbonate  of  soda  daily  (as  Vichy  water);  there 
was  no  loss  of  weight. 

The  red  corpuscles  rose  from    .  4,239,000 
to        .  5,910,000 

and  fell  after  stopping  the  alkali  in  twenty  days  to  4,480,000 

A  repetition  of  the  experiment  gave  a  similar  result.  M.  Pupier  was  led  to 
this  investigation  by  the  fact  that  the  red  corpuscles  in  a  man  who  had  taken  for 
a  fortnight  16-20  grms.  of  bicarbonate  of  soda  a  day  amounted 

to  5,406,000 

That  alkalies  increase  the  number  of  red  corpuscles  is  contrary  to  the 
opinion  generally  received. 

The  blood  from  the  finger  of  a  healthy  male  adult  showed  the 
Red  corpuscles  to  be       .       .  3,804,700 
White  corpuscles  to  be     .       .  4,062 
Ratio      .       .       .       .  1  to  937 

Bicarbonate  of  soda  4  grammes  three  times  a  day  was  taken  daily,  and  in  eight 
days  the  count  showed 

Red  corpuscles  .  .  .  3,344,380 
White  corpuscles  .  .  .  3,713 
Ratio  1  to  903 

Bicarbonate  of  potash  was  substituted  for  soda,  and  one  week  later  the 
Red  corpuscles  were        .       .  3,561,020 
White  corpuscles  were     .       .  3,385 
Ratio  1  to  1,050 

Bicarbonate  of  soda  again  used.  One  month  later  an  examination  of  the  blood 
showed  the 

Red  corpuscles  to  be  .  .  3,555,6^4 
White  corpuscles  to  be  .  .  6,973 
Ratio  1  to  515 

The  alkali  was  discontinued.    One  week  later  it  was  found  that  the 
Red  corpuscles  were        .       .  3,696,400 
White  corpuscles  were     .       .  4,365 
Ratio  1  to  869 

There  had  been  some  slight  dyspeptic  symptoms  while  the  drug  was  taken. 

There  was  therefore  a  slight  decrease  of  the  red  corpuscles,  and  a  slight 
increase  of  the  white. 

In  a  second  case  the  result  was  the  same ;  the  figures,  however,  were 
mislaid. 

Action  of  Quinia  on  Healthy  Subjects  -Bulgak2  reports  that  a  con- 
traction of  the  spleen  could  be  brought  about  by  injections  of  quinia  into 

1  Acad,  des  Sciences  Comptes  Rendus,  lxxx.  p.  1148, 1149. 
3  Quoted  in  the  Dublin  Journ.  of  Med.  Sci.,  Oct.  1876. 


1878.]  Is H AM ,  Parotiditis,  or  Mumps.  369 

the  veins,  causing  also  an  increase  in  the  number  of  the  white  corpuscles 
in  the  splenic  vein.    Ergot  had  no  effect. 

We  noticed  the  following  variation  in  the  globular  richness  during  the 
administration  of  quinia. 

Globular  richness  of  a  healthy  male  adult  at  2  P.  M.,  half  an  hour  after  a  slight 
lunch. 

Red  corpuscles  .  .  .  3,249,600 
White  corpuscles     .       .       .  5,754 

Ratio  1  to  566 

The  next  day  at  10  A.M.  .97  gramme  quinia?  sulph.  was  given,  causing,  from 

1  to  3  P.  M.,  a  slight  effect  upon  the  nervous  system.  Half  an  hour  after  a  lunch 
(the  same  as  on  the  previous  day)  at  2  P.  M.  the  count  was 

White  corpuscles  .  .  .  8,300 
Red        "  ...   

The  red  corpuscles  were  not  increased,  the  exact  figures,  however,  were  mislaid. 

On  the  next  day  1.29  grammes  quiniae  sulph.  were  given  at  10  A.  M.,  and  at 

2  P.  M.  the  effects  of  the  drug,  tinnitus  aurium,  slight  giddiness,  some  nervous 
excitement,  were  quite  marked.    An  examination  showed  the 

Red  corpuscles  to  be  .  .  2,978,600 
White  corpuscles  to  be    .       .  12,186 

Ratio  1  to  245 

On  the  next  day  no  quinia  was  taken ;  lunch  at  the  same  time  ;  at  2  P.  M.  the 
Red  corpuscles  numbered        .  3,422,902 
White  corpuscles  numbered     .  5,575 
Ratio  1  to  613 

The  habit  of  life  during  these  four  days  was  exactly  the  same  ;  the  lunch  was 
exactly  the  same. 

We  have  made  no  special  investigations  of  the  effect  of  quinia  given  in 
diseased  conditions.  In  one  case  of  syphilis  which  we  observed  there  was 
a  marked  increase  in  the  red  corpuscles,  1,043,130  under  the  administra- 
tion of  cinchonas  sulph. 

There  was  therefore  in  health  a  slight  diminution  in  the  number  of  red 
corpuscles,  and  a  marked  increase  in  the  number  of  the  white  after  the 
administration  of  a  large  dose  of  quinia?  sulph. 


Article  V. 

Parotiditis,  or  Mumps  ;  A  Theory  or  its  Etiology,  and  the  Ra- 
tionale of  the  Secondary  Manifestations,  or  so-called  Metas- 
tases. By  A.  B.  Tsham,  M.D.,  Professor  of  Physiology  in  the  Cincinnati 
College  of  Medicine  and  Surgery. 

Parotiditis,  or  mumps,  is  a  disease  which  primarily  affects  the  parotid 
gland,  usually  first  upon  one  side,  and  in  a  day,  or  two  extending  to  the 
other.  Both  glands,  however,  not  uncommonly  become  involved  at  the 
same  time ;  or,  more  rarely,  one  gland  only  may  be  attacked,  the  other 
remaining  unaffected  until  another  disease  visitation.  Consecutively,  the 
No.  CLII  Oct.  1878.  24 


370 


Is  ham,  Parotiditis,  or  Mumps. 


[Oct. 


submaxillary  and  sublingeal  glands  are  very  often  implicated.  It  is  a  dis- 
ease which,  as  a  rule,  occurs  but  once  in  the  same  individual.  The  ex- 
ceptions to  the  rule,  when  both  glands  have  been  the  seat  of  the  disease, 
are  very  rare. 

As  regards  etiology,  nothing  has  been  developed  since  the  days  of  Hip- 
pocrates. It  appears  in  all  seasons,  but  is  most  prevalent  in  fall  and 
winter.  It  occurs  in  mountain  districts,  table  lands,  valleys,  lowlands, 
islands,  and  upon  ship-board.  It  is  not  confined  within  degrees  of  latitude 
and  longitude.  It  prevails  as  an  epidemic,  or  rather  as  an  endemic,  and 
sporadic  cases  are  met  with.  The  latter  fact  tends  to  negative  any  agency 
in  causation  of  atmospheric  and  telluric  influences. 

Its  well-known  outbreak  among  new  recruits  in  camps,  among  the  in- 
mates of  boarding-schools  and  institutions,  when  no  cases  have  been  known 
to  exist  in  the  immediate  neighbourhood,  would  point  to  the  food  as  an 
etiological  element.  In  the  case  of  recruits,  at  their  homes  they  were 
accustomed  to  soft  food,  which  they  "  bolted"  with  but  little  mastication, 
and  consequently  little  stimulation  of  the  salivary  gland  secretion.  Fur- 
nished with  the  army  biscuit,  or  "hard  tack,"  however,  all  the  mastica- 
tory strength  is  called  forth.  This  mechanical  stimulus  of  jaw  movement 
is  supplemented  by  that  of  the  dryness  of  the  cracker.  The  secretion  ex- 
cited must  be  much  more  than  that  excited  by  a  dry  bread-crust,  which 
has  been  found  by  Tuczek  to  be  equal  to  the  bulk  of  the  crust.  The 
secreting  gland-cells,  under  this  excessive  and  unusual  secretion,  become 
distended,  and  finally  they  are  separated  from  the  basement  membrane, 
filling  up  the  tube,  and  causing  salivary  retention.  In  consequence  of 
the  gland  no  longer  equalizing  pressure  in  the  bloodvessels  by  removing 
fluid,  effusion  takes  place  into  the  connective  tissues  or  lymph  spaces,  and 
the  gland  swells.  This  simple  process  may  or  may  not  be  accompanied  by 
inflammation.  Analogous  changes  occur  in  the  kidney  tubules,  conse- 
quent upon  great  blood-pressure  from  any  cause. 

The  fact  that  both  parotids  are  very  often  not  affected  simultaneously 
is  not  opposed  to  this  view.  In  truth,  it  affords  an  easier  explanation 
than  the  contagious  catarrhal  theory  of  causation.  It  is  well  known  that 
in  many  persons  mastication  is  principally  one-sided.  Physiologists  have 
also  shown  that  the  secretion  of  saliva  occurs  upon  the  side  of  mastication. 
Where  the  two  glands  have  been  stimulated  unequally  by  one-sided  mas- 
tication, the  one  which  has  furnished  the  bulk  of  the  secretion  is  first 
involved,  the  ducts  being  filled  up  by  cast-off  epithelial  cells,  and  com- 
pressed by  the  pressure  of  effusion.  The  other  gland  then  assumes  the 
secretory  function  for  both,  but  from  having  been  functionally  inactive, 
and  from  the  burden  of  work  so  suddenly  put  upon  it,  proves  unequal  to 
the  office.  The  same  alterations  now  transpire  as  in  the  other  gland,  ob- 
struction, effusion,  and  enlargement,  with  perhaps  inflammation.  The 
advocates  of  the  catarrhal  hypothesis  put  in  the  plea  of  "extension  of  the 


1878.] 


I  SHAM  j  Parotiditis,  or  Mumps. 


371 


irritation."  Which  is  the  more  rational  explanation  ?  Where  both  sides 
have  been  equally  operated  upon  by  secretory  stimuli  they  are  attacked  at 
the  same  time. 

It  is  admitted  that  this  idea  of  etiology  receives  its  strongest  support  in 
its  application  to  endemics  in  camps  and  institutions  where  the  same  diet 
obtains  for  all.  Yet  those  endemics  occurring  in  communities  of  indi- 
vidual families,  and  the  sporadic  cases  presenting  everywhere,  while 
seemingly  in  opposition,  are  not  without  the  range  of  such  causation.  While 
the  separate  families  of  a  community  live  and  cook  differently,  they  are 
still  dependent  upon  the  same  sources  of  food  supply,  and  the  substantial 
articles  of  nutriment  are  the  same  for  all.  Food  varies  in  its  constitution 
according  to  season,  care,  culture,  etc. ;  the  more  solid  matter  it  contains 
the  greater  the  quantity  of  salivary  fluid  needed  to  moisten  and  act  upon 
it.  The  source  and  quantity  being  the  same,  it  is  evident  that  it  must 
act  about  the  same  in  each  family  of  the  community,  although  modified  in 
some  by  the  mode  of  preparation.  Here  most  of  those  not  protected  by 
a  previous  experience  will  be  affected,  but  others  obnoxious  to  the  trouble 
may  escape  by  reason  of  special  diet,  manner  of  food  preparation,  or  from 
constitutional  states  having  a  bearing  upon  the  quantity  of  food  ingested. 
Sporadic  cases  may  occur  through  causes  pertaining  to  the  individual, 
such  as  habits  of  chewing  wax,  dry  wood,  rubber,  tobacco,  etc.,  eruption 
of  the  teeth,  or  other  processes  acting  as  a  stimulus  to  the  salivary  secre- 
tion. These  etiological  elements  also  belong  to  endemic  visitation.  Or 
they  may  be  induced  by  individual  peculiarities,  certain  articles  of  food 
affecting  solitary  individuals  while  they  are  inoperative  upon  the  mass. 

But  this  view  must  fail  of  acceptation  if  it  is  not  competent  to  furnish  a 
solution  to  the  problem  of  non-recurrence,  or  why  the  affection  never,  or 
very  seldom,  recurs  in  the  same  individual.  Without  this  it  stands  equal 
witli  the  contagious  catarrhal  theory ;  but  this  is  not  enough.  There  is  a 
physiological  law  that  the  development  of  an  organ  must  be  proportionate 
to  the  amount  of  work  it  has  to  perform.  An  attack  of  specific  parotiditis 
indicates  that  the  gland  involved  has  not  attained  to  the  fulfilment  of  this 
law,  and  the  completion  of  development  is  at  once  begun.  New  vesicles 
and  lobules  branch  out,  new  epithelium  cells  are  formed.  Under  the  in,- 
fluence  of  this  formative  force,  effusions  and  waste  products  are  disposed 
of,  and  the  gland  reaches  its  acme  of  development,  and  is  equal  to  any 
amount  of  work  it  may  in  the  future  be  called  upon  to  perform. 

Favouring  the  representation  that  the  process  is  one  of  development  is 
the  fact  that  cases  of  mumps  are  most  common  about  the  period  of  puberty 
when  such  developmental  alterations  ensue  in  other  organs.  The  analo- 
gous changes  are  those  taking  place  in  the  testicles,  ovaries,  and  mammae. 
In  the  latter  innumerable  ramifications  branch  off  from  the  ducts  and  some 
vesicles  are  formed.    In  the  testicle  the  seminiferous  tubes  increase  in  size 


372 


I S  H  A  M ,  Parotiditis,  or  Mumps. 


[Oct. 


and  the  seminal  cells  or  vesicles  are  developed.  In  the  ovaries  the  follicles 
and  ova  become  enlarged. 

Instances  of  very  early  ovulation  and  mammary  development  are  not  by 
any  means  wanting,  as  every  one  knows.  Is  it,  therefore,  astonishing  that 
the  affection  known  as  mumps,  which  marks  the  full  development  of  the 
salivary  glands,  should  occur  more  frequently  than  the  mentioned  changes 
in  the  organs  above  named,  between  the  age  of  two  years  and  puberty, 
when  we  consider  the  thousand  times  greater  exercise  and  stimulation  to 
which  they  are  subjected  ? 

The  disturbance  therefore  should  take  place  more  often  about  the  period  of 
puberty,  because  this  is  the  time  when  general  changes  are  proceeding  in  the 
organism.  It  is  then  that  the  system  is  most  sensitive  to  extraneous  influ- 
ences and  the  salivary  glands  not  less  than  other  portions.  That  the  paro- 
tid affection  may  not  rarely  be  delayed  for  years  beyond  this  time  does  not 
seriously  militate  against  the  proposition.  The  retardation  of  development 
in  the  mamma)  and  ovaries  consequent  upon  morbid  states  as  phthisis,  epi- 
lepsy, scrofula,  etc.,  is  familiar.  Such  instances  serve  to  illustrate  the  fact 
that  processes  may  manifest  a  selection  for  parts  or  organs  of  the  body,  and 
through  their  operation  there  interfere  with  actions  in  other  parts  or  organs. 
Thus  the  alterations  in  the  generative  organs  and  apparatus  of  lactation, 
consequent  upon  the  advent  of  puberty,  may  be  so  active  as  to  consume  all 
the  formative  force  in  the  organism,  and  the  salivary  glands  will  remain  as 
before.  The  longer  after  puberty,  however,  the  change  is  delayed  the 
more  marked  is  likely  to  be  its  reaction  upon  the  system,  because,  after  this 
time  the  body  elements  tend  to  become  more  and  more  fixed.  It  is  this 
which  gives  significance  to  the  popular  expression,  "  the  mumps  go  hard 
with  grown  people." 

We  come  now  to  consider  the  so-called  metastatic  phenomena  of  the 
affection.  Where  these  occur  it  is  usually  five  to  eight  days  after  the  com- 
mencement of  the  parotid  trouble.  In  the  matter  of  frequency  as  gathered 
from  writers,  parts  become  involved  in  about  the  following  order :  testes, 
mammae,  ovaries,  labia  majora,  lymph  glands,  spleen,  and  brain.  Leich- 
tenstern  (Handb.  d.  Kind.  Kranhh.)  mentions  nephritis  and  catarrh  of  the 
bladder,  urethra,  and  vagina  as  rare  occurrences.  Dr.  Dunn  (North  of  Eng. 
Med.  and  Surg.  Journ.,  and  Amer.  Journ.  Med.  Set.,  1831)  reports  four 
cases  of  mumps  with  inflammation  of  vagina  and  purulent  discharge  follow- 
ing. While  it  is  asserted  by  some  systemic  writers  that  transference  of  the 
disease  process  to  the  ovaries  never  transpires,  others  place  it  next  in  fre- 
quency after  affection  of  the  mammae.  The  literature  of  the  subject  is  ex- 
ceedingly scanty.  IS  o  citation  of  cases  is  given  in  works,  and  we  have  only 
found  three  cases  reported  in  the  journals,  two  by  Damorest,  and  one  by 
Meyner  (Clinic,  Oct.  1876).  On  the  other  hand,  while  in  all  the  treatises 
involvement  of  the  mammae  in  females  is  placed  next  in  order  of  frequency 
to  the  testicles  in  the  male,  no  references  are  given.    After  examination  of 


1878.] 


I  sham,  Parotiditis,  or  Mumps. 


373 


a  wide  range  of  journals,  English  and  German,  we  have  not  been  fortunate 
enough  to  find  a  single  case  recorded  where  these  organs  were  implicated. 
Can  it  be  possible  that  the  authority  of  the  traditional  "  old  woman"  was 
first  accepted  for  this  complication  without  credit,  and  so  has  been  seized 
upon  by  one  author  after  another  ?  Rilliet,  who  has  given  us  the  most  com- 
plete description  of  parotiditis  extant,  did  not  observe  a  single  case  of  en- 
largement of  the  mammas,  and  other  writers  specifically  state  that  they  have 
never  met  with  it.  We,  therefore,  believe  that  the  ovaries  are  more  fre- 
quently affected  from  parotiditis  in  females  than  other  organs  in  this  sex, 
but  from  the  well-known  obscurity  of  the  symptoms,  or  from  the  modesty  of 
these  persons,  it  is  not  detected.  Irritation  of  the  stomach  and  intestinal 
tract  is  not  specifically  noticed,  but  that  it  occurs,  the  symptoms  of  anorexia, 
nausea,  fever,  and  diarrhoea  in  many  instances  abundantly  exhibit. 

No  example  has  been  recorded  as  far  as  our  investigation  has  been  car- 
ried in  which  parotiditis  had  a  relation  to  endocarditis,  and  the  opportunity 
of  supplying  this  hiatus  is  embraced  by  offering  the  following  from  our 
note-book. 

Carrie  M.,  a?t.  4  years,  brought  to  office  Aug.  2,  1873,  complains  of  las- 
situde ;  feverish  in  the  afternoon  and  evening  ;  no  appetite  ;  tongue  slightly 
coated ;  bowels  regular.  Suitable  medication  prescribed.  3d.  Condition 
about  the  same.  4th.  Missed  her  fever  and  she  was  seen  no  more  until  the 
7th  when  I  was  called  in  on  account  of  a  swelling  in  the  right  parotid 
region.  The  parotid  of  that  side  was  regularly  enlarged  and  firm.  No 
congestion  of  pharynx  and  fauces.  There  was  no  fever.  On  the  8th  both 
parotid  regions  were  swollen  and  she  had  fever.  The  urine  was  high 
coloured,  and  upon  examination  was  found  to  contain  blood  disks,  tube  casts, 
and  to  be  albuminous.  On  the  9th  her  mother  assumed  the  responsibility 
of  taking  her  a  walk  through  Eden  Park.  Called  to  her  in  the  night. 
There  was  violent  fever,  delirium,  dyspnoea,  excited  action  of  the  heart, 
visible  heaving  impulse,  and  a  murmur  having  the  characters  both  of  a 
blowing  and  a  friction  murmur,  double  with  reference  to  the  sounds  but 
most  plainly  systolic  as  nearly  as  could  be  distinguished  under  the  very 
rapid  action.  There  was  also  discovered  some  amount  of  ascites.  These 
morbid  appearances  all  disappeared  under  treatment  and  time,  good  re- 
covery ensuing. 

It  thus  appears  that  any  organ  of  the  body  except  the  liver  and  lungs, 
may  become  the  seat  of  what  has  been  termed  a  metastasis  in  mumps. 
Why  these  organs  apparently  are  exempt,  others  nearly  so,  and  yet  others 
specially  selected  to  share  in  the  morbid  expression  it  will  be  the  endeavour 
to  elucidate.  In  doing  so  it  will  be  first  necessary  to  inquire  what  influ- 
ence the  parotid  secretion  retained  in  the  blood  might  exert  upon  the  sys- 
tem. At  the  very  commencement  it  must  be  confessed  that  nothing  is 
really  known  respecting  the  vital  chemistry  of  the  salivary  secretion  further 
than  that  it  forms  from  the  blood  ptyalin,  a  ferment  which  induces  a  sac- 
charine conversion  of  starch,  together  with  sulpho-cyanide  of  potassium, 
and  the  sodium  and  potassium  chlorides  and  phosphates.  It  is  to  be  held 
as  an  excretory  product  of  the  nutritive  fluid,  for,  although  it  is  reabsorbed, 


374 


Isham,  Parotiditis,  or  Mumps. 


[Oct. 


yet,  from  contact  with  food  and  digestive  juices  its  principles  have  under- 
gone such  metabolism  that  they  are  wholly  changed.  Being  thus  entitled 
to  esteem  it  as  an  excretion  it  may  be  assumed  to  bear  a  comparison  with 
other  excretions,  the  retention  of  which  in  the  circulating  fluid  we  have 
definite  information  concerning.  Taking  the  quantity  secreted  daily  by  an 
average  adult  man,  which  is  calculated  at  about  three  pints,  it  has  an  im- 
portant place  among  the  excrementitious  fluids. 

Classing  the  peculiar  salivary  constituents,  then,  as  matters  to  be  sepa- 
rated from  the  blood,  it  follows  that  their  retention  in  the  blood  or  their 
entrance  into  it  as  salivary  principles  would  be  productive  of  mischief. 
When  the  urinary  excretion  is  arrested,  there  are  present  the  morbid  appear- 
ances designated  as  urasmia.  When  the  biliary  flow  is  impeded,  the  con- 
dition recognized  as  cholesteraemia  or  jaundice  ensue-. 

But  before  proceeding  further  it  may  be  as  well  to  establish  that  salivary 
retention  occurs.  Bouchet  declares  that  parotiditis  is  simply  salivary  re- 
tention due  to  catarrhal  inflammation  of  the  excretory  duct  of  the  parotid 
gland.  Virchow  holds  it  to  be  an  inflammation  of  the  gland  duets  with 
salivary  retention  and  oedema  of  the  interstitial  tissue.  These  are  about 
the  only  emphatic  utterances  nu  t  with.  That  an  inflammatory  condition 
of  the  duct  or  of  the  gland  may  set  up  is  no  wise  opposed  to  the  etiology 
and  pathology  advocated  in  this  paper. 

The  question  immediately  arises,  if  salivary  retention  may  prove  so  hurt- 
ful why  is  it  that  every  case  of  mumps  is  not  accompanied  by  more  serious 
disturbances  ?  This  inquiry  may  be  satisfied  by  a  reference  to  the  fact 
that  the  submaxillary  gland  secretion  although  more  viscid  contains  the  same 
principles  as  that  of  the  parotid,  and  that  under  disability  of  the  latter,  the 
former,  together  with  the  sublingual,  may  perform  its  depurative  function. 
Of  some  interest  here  are  the  results  of  the  experimentation  of  Heiden- 
hain  upon  dogs.  He  found  that  galvanic  stimulation  of  the  chorda  tym- 
pani  produced  a  watery  secretion,  and  that  under  long-continued  excitation 
of  the  sympathetic,  the  submaxillary  secretion  acquired  the  watery  consist- 
ence of  the  parotid  fluid.  When,  however,  the  submaxillary  and  sublin- 
gual glands  become  involved  in  addition  to  the  parotids,  we  have  absolute 
retention,  with  entrance  into  the  blood  of  the  salivary  principles.  Then 
marked  evidences  of  systemic  infection  should  be  expected  and  they  do 
occur ;  these  are  the  so-called  metastases. 

The  meaning  conveyed  by  the  term  metastases  is  that  there  is  a  sudden 
shifting  of  the  process  from  one  point  to  another  with  complete  removal  of 
morbid  action  from  the  original  seat.  The  majority  of  writers  assert  that 
they  have  never  observed  a  sudden  resolution  in  one  part  coincidently  with 
a  spread  to  another,  and  they  believe  that  it  occurs  very  exceptionally  or 
not  at  all.  They  have  only  noticed  the  same  gradual  subsidence  in  the 
parotid,  under  such  circumstances,  as  usually  occurs  without  complication, 
in  six  to  ten  days  from  commencement  of  swelling.    The  metastatic  phe- 


1878.] 


I  sham,  Parotiditis,  or  Mumps. 


375 


nomena  also  gradually  disappear  in  a  like  period  of  time.  Since  the 
mater ies  morbi  are  retained  excretory  products  in  the  blood,  as  herein  set 
forth,  these  principles  are  carried  in  the  blood  stream  to  all  organs  of  the 
body  and  they  may,  at  any  time,  create  a  disturbance  in  any  part  without 
a  transposition  of  all  the  disease  appearances  to  this  locality.  There  is 
really  no  metastasis,  as  we  interpret  this  term,  the  outbreak  in  a  part  re- 
mote from  the  original  seat  simply  being  an  expression  of  a  systemic  poi- 
son. The  involvement  of  a  new  organ,  as  the  testicle,  may  occur  just  at 
the  subsidence  of  the  parotid  swelling  as  well  as  at  any  other  time,  and  this 
is  likely  what  has  given  rise  to  the  idea  of  metastasis  or  sudden  transfer- 
ence. 

We  are  now  brought  to  the  task  of  showing  why  parotiditis  is  not  more 
frequently  attended  with  complications,  why  some  organs  do  not  become 
implicated  at  all,  and  others  are  specially  obnoxious  to  the  action  of  the 
morbific  material. 

The  lungs  owe  their  exemption  to  the  office  which  they  perform  in  blood 
depuration.  Sugar,  a  substance  which  when  present  in  quantity  in  blood 
occasions  the  fatal  disease  diabetes,  is  destroyed  by  passage  through  the 
lungs.  Sulphuretted  hydrogen  when  present  in  the  air,  even  in  minute 
quantities,  is  fatal  to  birds ;  but  when  it  is  injected  into  the  blood,  it  is  at 
once  eliminated  by  the  lungs,  and  no  harm  ensues.  Not  only  are  the  pul- 
monary structures  protected  by  this  depurative  function  of  the  respiratory 
apparatus,  but  it  exerts  a  protective  influence  also  over  all  other  parts  of 
the  body.  Where  the  noxious  matter  is  not  too  great,  it  may  all  be  elimi- 
nated by  the  lungs  in  connection  with  the  liver,  kidneys,  skin,  and  alimen- 
tary tract  and  complications  be  prevented. 

The  liver  also  is  indebted  for  its  freedom  from  disturbance  to  the  same 
property  it  possesses  of  separating  deleterious  substances  from  the  blood. 
Schiff  has  recently  demonstrated  by  experiment  that  a  dose  of  nicotin  suf- 
ficiently large  to  kill  a  large  dog,  if  injected  into  the  general  circulation, 
only  produced  feeble  symptoms  of  poisoning  when  injected  into  the  mesen- 
teric veins  and  small  intestines  of  other  dogs.  A  double  dose,  passed 
through  the  liver  before  entering  the  general  circulation,  did  not  kill  a 
dog.  On  the  other  hand,  an  injection  five  times  diluted  killed  an  animal 
in  which  the  portal  vein  was  tied.  Cholesterine,  too,  a  poisonous  product, 
is  removed  by  the  liver.  It  is  evident  that  this  function  of  the  liver  exer- 
cises a  general  protective  influence  as  already  sufficiently  mentioned  in 
connection  with  the  lungs. 

The  comparative  rarity  of  kidney  disturbance  is  also  due  to  a  similar 
action  in  blood  purification.  Dr.  Letheby  has  shown  that  poisonous  doses 
of  arsenic  may  be  repeatedly  given  to  animals  without  injury,  if  a  diuretic 
is  administered  at  the  same  time.  It  is  also  the  constant  office  of  the  kid- 
neys to  carry  off  urea,  which,  if  retained,  causes  uraemic  poisoning  with  its 
dangers.    That  these  organs,  however,  should  sometimes  become  the  thea- 


376 


Ish AM,  Parotiditis,  or  Mumps. 


[Oct. 


tre  of  the  morbid  action,  is  not  strange,  from  the  constantly  increasing 
blood  pressure  they  must  sustain  under  the  work  put  upon  them  in  dis- 
posing of  the  poison.  Here  the  pathological  incident  is  that  known  as 
acute  catarrhal  nephritis,  an  example  of  which  lias  been  given  in  the  de- 
tailed case  already  here  reported.  The  secreting  cells  are  washed  off,  the 
tubules  blocked  up,  and  inflammatory  changes  ensue  as  may  also  take 
place  in  the  parotid. 

The  testicles  and  ovaries,  the  organs  most  often  selected  in  the  secondary 
manifestations,  present  anatomical  peculiarities  which  are  possessed  by  no 
other  organs  in  the  body,  save  the  liver  and  kidneys.  They  are  furnished 
with  a  double  set  of  capillary  plexuses.  It  is  plain  that  the  greater  the 
amount  of  vascular  area  of  an  organ,  the  greater  is  its  liability  to  become 
impressed  by  a  blood  poison  circulating  through  it.  In  the  liver  and 
kidneys  this  extra  liability  is  amply  offset  by  their  previously  noticed 
eliminatory  action  upon  noxious  products.  Another  anatomical  condition 
bearing  upon  the  selection  of  the  testicles  and  ovaries  is  that  they  are  lo- 
cated at  the  lowest  portion  of  the  body  where  gravity  or  anything  opposing 
a  hindrance  to  the  onward  flow  of  the  blood  current  must  operate  upon 
them  to  the  fullest  extent.  An  erethism  of  these  organs  which  exists  in 
certain  persons  also  predisposes  to  their  involvement.  Thus  of  twelve 
cases  occurring  in  sailors  on  ship-board  reported  by  Dr.  Lynch  (B ra it h - 
waiters  Retros.,  185G-7,  ii.  2G),  the  testicles  were  affected  in  ten  and  the 
brain  in  two.  It  is  sufficient  to  call  attention  to  the  increased  excitability 
of  the  sexual  organs  in  sailors,  or  the  generality  of  men  pent  up  or  con- 
fined anywhere,  to  account  for  the  preference  manifested  in  these  cases. 
It  is  also  well  attested  by  many  observers  that  implication  of  the  testicles 
is  not  nearly  so  common  in  children. 

Why  the  right  testicle  should  be  selected  in  preference  to  the  left,  as 
noticed  by  Rilliet,  we  are  not  prepared  to  explain.  This  observer  noticed 
that  out  of  23  cases  the  right  side  was  affected  13  times,  the  left  6  times, 
and  in  4  both  testes  suffered  together.  We  would  suppose  the  contrary 
to  obtain,  since  upon  the  left  side  varicocele  is  twice  as  common  as  upon 
the  right,  due,  as  first  pointed  out  by  Brinton  in  this  Journal,  to  the  right 
spermatic  vein  being  supplied  with  a  valve  at  its  outlet,  while  the  left  has 
none. 

Ressiguer  (Gaz.  Med.,  1850;  Med.-Chir.  Rev.,  Oct.  1850)  mentions  a 
case  under  his  observation  where  there  was  orchitis  without  parotiditis, 
but  which  subsequently  developed.  He  also  cites  a  similar  case  by  Groffier. 
In  reference  to  these  cases  it  may  be  said  that  while  parotid  enlargement 
had  not  appeared,  yet  there  was  obstruction  and  interference  with  the 
"  secretion  and  systemic  infection  as  shown  by  the  affection  of  the  testes. 

The  lymphatics  are  absorbents,  and  no  time  need  be  occupied  in  enlarg- 
ing upon  how  readily  the  lymph  glands  are  acted  upon  by  matters  taken 
to  them  by  the  lymphatics  under  systemic  infection.    The  spleen,  too, 


1878.] 


I  s  h  A  M ,  Parotiditis,  or  Mumps. 


377 


which  is  designated  as  a  blood  gland,  must  not  rarely  be  disturbed  by  any 
impurity  of  the  common  nutritive  fluid.  How  dependent  the  brain  in  the 
exercise  of  its  functions  is  upon  a  pure  circulating  juice  the  most  limited 
experience  must  appreciate.  The  cells  of  the  gray  matter  cannot  properly 
functionate  upon  depraved  blood,  and  we  may  have  all  forms  of  disordered 
cerebral  phenomena  under  such  circumstances. 

The  mammary  glands  have  been  reserved  to  the  last,  and  purposely. 
From  what  has  been  found  written  upon  the  subject  we  feel  satisfied  that 
secondary  disturbances  in  these  organs  are  among  the  rarest  appearances 
of  the  disease.  These  glands  are  exposed  not  more  or  less  to  the  morbid 
influence  than  other  organs,  which  are  among  the  least  affected. 

A  word  in  regard  to  hypertrophies  of  the  testicles  and  mammae,  which 
are  mentioned  as  very  rare  sequelae.  It  is  of  course  a  matter  of  not  diffi- 
cult demonstration  that  from  pressure  and  distension  of  effusion,  or  from 
inflammatory  changes,  the  special  vital  activity  of  apart  becomes  lost,  and 
it  hypertrophies,  because  the  energy  which  was  stored  up  in  its  structure 
has  gone  out  of  it. 

Finally  is  reached  the  action  of  reputed  remedies.  How  do  they  accord 
with  the  views  herein  advanced?  Dr.  Czernicke  reports  (Gaz.  Hebd.  de 
Med.  et  Chir.,  No.  15,  1875;  and  Clinic,  1875)  a  case  of  orchitis  from 
metastasis  of  mumps  successfully  treated  by  jaborandi.  To  the  increased 
functional  activity  excited  in  the  salivary  glands  by  the  sialagogue  pro- 
perty of  this  drug  is  ascribed  a  diversion  of  the  metastasis.  Emery  Des- 
brouses  reports  a  similar  case  successfully  treated  by  the  same  remedy. 
(Same  Journal,  April  30,  1875  ;  also  Clinic,  1875.)  Dr.  Eldridge,  of 
New  York,  never  fails  to  cure  parotiditis  by  an  emetic  in  12  or  24  hours. 
{Med.  and  Surg.  Rep.,  vol.  xxvi.) 

Let  us  examine  how  effusion  or  dropsy  occurs,  and  how  absorption  is 
produced.  Under  active  vascular  flow  to  an  organ,  as  the  parotid  gland, 
the  capillaries  become  dilated  and  permit  free  passage  of  blood  through 
them  into  the  veins  ;  the  arterial  pressure  is  reduced,  but  venous  pressure 
is  enhanced.  In  the  usual  state  of  blood-flow  there  is  some  transudation 
of  serum  into  the  lymph  spaces.  This  is  constantly  being  removed  by  the 
capillary  lymphatics,  which,  according  to  Recklinghausen,  are  everywhere 
distributed  in  the  tissues  in  intimate  relation  with  the  bloodvessels  through 
the  lymph  spaces.  But  where  there  is  capillary  repletion  with  exalted 
pressure  in  venous  trunks,  there  is  a  greater  amount  of  serum  exuded  into 
the  lymph  spaces  than  the  lymphatics  are  competent  to  remove.  When 
the  secreting  apparatus  of  the  organ  is  in  order,  this  surplus  fluid  is  dis- 
posed of  by  appropriating  it  for  secretion.  But  when  the  secretory  struc- 
tures are  not  operative,  as  in  parotiditis,  it  accumulates  in  the  lymph  spaces 
or  connective  tissue,  constituting  effusion  or  dropsy. 

It  is,  however,  evident  that  this  effusion  can  only  increase  to  a  certain 
extent.    The  pressure  of  the  exuded  fluid  constricts  the  capillaries,  exalts 


378 


Is  ham,  Parotiditis,  or  Mumps. 


[Oct. 


the  pressure  in  the  arteries  and  lowers  it  in  the  veins.  The  pressure  ex- 
erted by  the  serum  in  the  lymph  spaces  is  now  favourable  to  drainage  through 
the  lymphatic  vessels,  since  hindrance  to  the  flow  through  the  lymph 
trunks  has  been  obviated  by  removal  of  venous  pressure.  Compensatory 
channels  of  circulation  have  also  become  established,  and  these  make  tribu- 
tary vessels  from  the  overflowed  district,  and  so  assist  in  draining  it.  The 
effused  fluid  has  also  become  thinner  from  a  loss  of  its  salts.  When  now 
there  follows  an  increase  in  the  blood-flow  through  the  capillaries  proper 
to  the  part,  in  consequence  of  removal  of  some  of  the  effusion  by  the  lymph 
vessels  and  compensatory  channels,  absorption  into  the  blood  takes  place, 
although  there  is  increased  venous  pressure.  It  occurs  more  rapidly,  too. 
because  the  power  of  osmosis  with  which  a  thin  liquid  passes  through  into 
a  denser  is  very  great. 

Such  is  the  phenomena  of  effusion  and  absorption  as  it  may  occur  any- 
where. In  the  parotid  gland,  however,  there  is  another  favouring  element 
in  .  absorption  to  be  considered.  The  washed-off  cells,  which  in  the  first 
place  cause  the  obstruction  in  the  ducts,  may  be  compared  to  bladders 
which  are  filled  to  bursting.  Under  the  extreme  of  tension  they  burst, 
allow  the  contents  of  the  tubes  to  be  flushed  out,  and  permit  the  new  cells 
to  exercise  their  function  of  secretion.  Thus  another  important  channel  is 
opened  for  the  relief  of  overflow. 

We  return  now  to  the  action  of  jaborandi  and  emetics.  The  time  when 
such  agents  would  be  likely  to  be  employed  would  be  in  the  stage  of  greatest 
enlargement,  just  before  the  decline.  Jaborandi  is  to  be  classed  as  an 
emetic.  While  it  may  exert  a  sialagogue  and  sudorific  action  without  emesis, 
just  so  may  ipecac,  belonging  to  the  emetic  class,  which  is  absorbed  into 
the  blood  and  acts  precisely  as  jaborandi.  They  cause  dilatation  of,  and 
retardation  of  flow  through,  the  surface  capillaries  by  paralysis  of  the 
sympathetic  fibres  distributed  to  them.  Hence  we  have  copious  sweating 
and  secretions  from  mucous  surfaces. 

In  the  case  of  parotid  enlargement.  The  increased  blood-pressure  in 
the  parts  contiguous  would  tend  to  augment  the  pressure  exerted  upon  the 
ducts  and  clear  them  of  their  obstruction  by  bursting  the  occluding  cells. 
The  secretory  activity  of  the  gland  would  also  be  stimulated  through  the 
afferent  nerve  fibres,  by  the  taste  impression,  and  also  by  the  relaxation  of 
the  sympathetic.  In  this  way  the  tubes  would  be  flushed  out  and  relieved 
of  all  impediment. 

It  is  clear  that  this  enhanced  pressure  in  tegumental  structures,  which 
relieves  itself  by  such  remarkable  overflow  upon  the  surface  and  into  the 
mucous  passages,  would  exercise  a  powerful  depletory  effect  upon  any  part 
the  seat  of  effusion.  It  must  speedily  reduce  the  tumefaction,  whether  the 
organ  possess  within  itself  any  active  excretory  office  or  not. 


1878.] 


Sinklee,  Spinal  Paralysis  of  the  Adult. 


379 


Article  VI. 

Five  Cases  of  Spinal  Paralysis  of  the  Adult.  By  Wharton 
Sixkler,  M.D.,  Attending  Physician  to  the  Orthopedic  Hospital  and  In- 
firmary for  Nervous  Diseases,  Philadelphia. 

It  is  now  several  years  since  it  has  been  recognized  that  there  is  an 
affection  in  adults  which  is  almost  identical  with  the  disease  so  frequently 
met  with  in  children,  called  infantile  spinal  paralysis. 

The  number  of  cases  already  reported  is  comparatively  small,  and  there 
are  still  some  points  in  the  history  of  the  disease  which  are  obscure,  so 
that  new  light  may  be  thrown  on  the  subject  by  the  bringing  forward  of 
additional  cases.    This  is  my  reason  for  offering  the  following  histories: — 

Case  I — P.  P.,  bartender,  aet.  59  years,  male ;  came  to  my  clinic  at 
Infirmary  for  Nervous  Diseases,  March  19,  1873.  Healthy  until  present 
trouble.  Went  to  bed  well,  with  exception  of  a  "  cold,"  one  night  in  Sep- 
tember, 1870.  Took  a  diaphoretic  powder  before  retiring,  and  sweated 
very  freely.  Next  morning  he  went  into  his  bar-room,  the  floor  of  which 
was  wet  from  having  been  scrubbed,  and  remained  there  for  several  hours. 
During  the  morning  he  noticed  that  the  right  leg  was  weak,  and  this 
weakness  extended  to  the  other.  In  a  week  both  legs  were  so  feeble  that 
he  could  not  use  them  at  all.  The  same  was  true  of  the  arms.  During 
this  time  he  had  severe  pain  in  the  back,  but  there  was  none  in  the  limbs, 
and  sensibility  to  touch  was  not  impaired.  There  were  no  cramps  of  the 
muscles.  High  fever  lasted  for  the  first  week  of  the  attack,  and  after  this 
it  left  gradually.  During  this  time  the  paralysis  became  complete,  and 
the  only  movement  that  remained  was  the  power  of  moving  the  fingers. 
There  was  no  paralysis  of  the  bladder  or  rectum.  At  the  end  of  a  week 
he  began  to  use  the  arms.  He  was  confined  to  bed  for  four  weeks,  when 
he  began  to  walk  with  assistance.  He  states  that  for  some  weeks  both 
feet  were  swollen.    Gradual  improvement  has  continued  until  now. 

Present  condition  Walks  with  a  cane,  but  can  Avalk  without  one.  He 

has  good  grip  of  both  hands,  and  has  all  the  movements  of  the  hands  and 
forearms,  but  cannot  raise  either  arm  from  the  side.  Both  deltoids  are 
extremely  atrophied,  and  so  are  the  infra-spinate  muscles ;  left  trapezius 
somewhat  wasted ;  no  wasting  of  any  other  muscle.  Still  suffers  from 
dorsal  pain  occasionally.  Has  no  cerebral  symptoms  ;  digestion  good  ; 
right  leg  eczematous  and  swollen  ;  there  is  no  oedema  of  the  feet. 

Electrical  condition  Both  infra-spinati  respond  to  a  strong  induced 

current.  Posterior  fibres  of  left  deltoid  can  be  stirred  by  the  same  cur- 
rent, but  the  anterior  fibres  of  this  muscle  and  the  whole  of  the  right  del 
toid  fail  to  respond  to  the  strongest  current.  The  pectoral  and  rhomboid 
muscles  act  well ;  biceps  and  triceps  respond  feebly.  Sixteen  cells  of  the 
constant  current  move  the  deltoids.  Electro-muscular  sensibility  de- 
cidedly impaired. 

The  patient  did  not  come  for  treatment  but  once  or  twice,  so  no  result 
could  be  obtained.  The  atrophy  of  the  deltoids  in  this  case  was  extreme, 
and  the  contrast  with  the  well-developed  arm  presented  a  singular  ap- 
pearance. 

Case  II  C.  T.  L.,  aet.  46;  has  never  had  syphilis;  temperate; 

harness-maker  by  occupation.    General  health  has  been  good,  with  the 


380 


Sinkler,  Spinal  Paralysis  of  the  Adult. 


[Oct. 


exception  of  attacks  of  asthma,  the  first  of  which  was  eighteen  years  ago ; 
but  there  was  an  interval  of  several  years,  during  which  he  had  no 
asthma.  He  had  an  attack  three  years  ago,  which  lasted  three  weeks. 
He  ascribes  this  attack  to  his  having  worked  in  a  damp  cellar  about  a 
year  previous,  but  since  then  he  has  worked  in  a  dry  place.  Has  had 
frequent  attacks  of  asthma  of  greater  or  less  severity  during  the  past  three 
years.  In  February,  1877,  a  bad  attack  began,  and  it  continued  without 
entire  relief  until  the  present  time.  He  became  very  weak,  and  in  May 
he  lost  the  power  of  walking.  About  this  time  there  began  to  be  loss  of 
sensation  in  the  hands  and  feet ;  he  could  not  button  his  shirt  on  account 
of  inability  to  feel  the  buttons,  and  the  feet  felt  as  if  there  was  thick  paper 
covering  the  soles. 

Shortly  after  this,  that  is,  about  the  beginning  of  June,  he  lost  power  in 
the  fingers  completely.  This  extended  to  the  arms  and  legs,  and  in  less 
than  two  Aveeks  he  could  not  stir  a  muscle  of  the  extremities ;  nor  was  he 
able  to  sit  up,  or  even  to  turn  over  in  bed.  There  was  no  paralysis  of  the 
bladder  or  of  the  rectum.  There  was  no  pain  in  the  back,  nor  hyperes- 
thesia of  the  surface  ;  neither  was  there  any  great  loss  of  sensation. 
There  was  no  formation  of  bed-sores. 

In  July  he  regained  the  power  of  moving  the  arms  to  a  slight  extent, 
and  became  able  to  turn  in  bed  ;  in  August  began  to  stir  the  legs  a  little. 

I  saw  the  patient  in  consultation  with  Dr.  Davidson,  who  had  been  in 
attendance  several  weeks,  early  in  September,  and  found  the  following 
condition  :  Patient  able  to  sit  up  alone.  Muscles  of  arms  and  legs  atro- 
phied ;  hands  and  feet  swollen  ;  palms  of  hands  sensitive  and  tender  from 
the  recent  desquamation  of  thickened  epidermis.  Can  extend  arms,  and 
can  flex  and  extend  forearms  ;  can  neither  flex  nor  extend  wrist ;  flexes 
and  extends  fingers  of  left  hand  slightly,  and  those  of  the  right  hand  very 
feebly.  Can  flex  and  extend  thighs  ;  has  but  little  movement  of  the  legs, 
and  none  of  the  feet  or  toes. 

Sensation  Palms  are  hypera?sthetic  to  touch,  but  there  is  impairment 

of  power  to  distinguish  compass  points.  Is  able  to  locate  touch  well.  In 
the  feet  the  sensibility  is  poor,  but  he  can  feel  and  localize  deep  touch.  A 
few  weeks  ago  there  was  a  sense  of  constriction  around  the  wrists,  but  that 
no  longer  exists.  There  are  no  reflex  movements  of  legs  excited  by  tick- 
ling the  soles,  and  no  reflex  testicular  movements  from  irritation  of  the 
inside  of  the  thighs. 

Electrical  condition  To  the  faradic  current  there  is  good  response  in 

biceps  and  triceps,  both  arms.  In  the  left  arm  the  extensors  and  flexors 
are  moved  by  a  strong  current,  but  the  interossei  do  not  act.  The  muscles 
of  the  right  forearm  require  a  still  more  powerful  current  to  produce 
movements.  There  is  no  electro-muscular  contractility  in  the  left  thigh 
or  leg,  or  in  the  right  leg ;  but  the  right  thigh  muscles  respond  slightly. 
The  constant  current  was  not  used.  The  left  arm  is  the  stronger  of  the 
two.  and  the  right  leg  is  stronger  than  the  left.  Bowels  are  regular  ;  urine 
normal ;  appetite  good.  Still  suffers  from  attacks  of  asthma  at  night. 
Heart  and  lungs  healthy. 

I  admitted  the  case  to  the  Infirmary  for  Nervous  Diseases,  November 
10,  1877.  The  following  treatment  was  adopted:  Iodide  of  potassium  in 
increasing  doses  until  one  hundred  grains  daily  were  taken  :  it  was  then 
reduced,  and  again  increased.  Massage  and  faradization  of  the  limbs 
were  used  on  alternate  days,  and  strychnia  and  cod-liver  oil  were  also 
administered.    Under  this  plan  the  patient  steadily,  although  slowly, 


1878.] 


Sinkler,  Spinal  Paralysis  of  the  Adult. 


381 


gained  strength;  and  on  June  12,  1878,  just  after  his  discharge  from  the 
hospital,  the  following  note  was  taken  :  "  He  is  able  to  get  up  unaided 
from  a  chair,  and  walks  about  with  freedom.  He  still  throws  the  foot 
down  with  a  flap.  Can  extend  and  flex  both  legs  ;  can  extend  both  feet, 
but  is  able  to  flex  them  only  slightly  ;  has  all  other  movements  of  legs ; 
has  all  the  movements  of  arms  ;  flexes  and  extends  wrists  and  fingers,  but 
the  latter  movements  are  interfered  with  by  stiffness  of  carpo-phalangeal 
joints.  Cannot  make  a  complete  fist,  nor  can  he  approximate  thumb  and 
forefinger.  The  interossei  muscles  and  thenar  eminences  are  atrophied. 
There  is  no  abnormal  appearance  of  the  skin  of  the  hands;  but  a  sense  of 
prickling  of  the  ends  of  the  fingers  may  still  be  produced  by  passing  com- 
pass points  over  them.  Sensation  still  impaired;  compass  points,  sepa- 
rated seven  lines,  are  felt  as  one;  at  nine  lines  they  are  distinguished. 
Localization  of  touch  good.  Leg  muscles  do  not  respond  to  secondary  in- 
duced current,  full  strength  of  battery,  but  the  constant  current  moves 
them." 

This  is  one  of  the  instances  which  are  occasionally  met  with  of  im- 
provement in  muscular  power  without  any  gain  in  the  ability  of  the 
muscles  to  respond  to  electrical  stimulus. 

The  large  doses  of  the  iodide  of  potassium  were  given  with  a  view  of 
controlling  the  attacks  of  asthma,  but  no  doubt  they  also  aided  in  improv- 
ing the  condition  of  the  cord. 

Aug.  12.  I  saw  the  patient  again  to-day;  he  is  now  able  to  approxi- 
mate the  thumb  and  forefinger  of  the  left  hand,  although  not  yet  able  to 
perform  this  movement  with  the  right  hand. 

The  following  case  was  in  the  Infirmary  for  Nervous  Diseases  under  the 
care  of  my  colleague,  Dr.  S.  Weir  Mitchell,  for  several  months  in  1876, 
and  while  there  I  had  frequent  opportunities  for  seeing  the  patient.  I 
re-examined  him,  and  took  the  following  history  on  August  29,  1877. 

Case  III  F.  E.  T.,  ast.  24  years,  a  native  of  Pennsylvania,  sailor  by 

occupation.  Says  he  has  never  had  syphilis,  and  that  he  is  temperate  as 
to  liquor. 

In  the  spring  of  1873  he  received  an  injury  from  slipping  while  rolling 
logs ;  he  got  a  wrench,  and  had  pain  and  stiffness  in  the  loins  for  two 
weeks.  About  two  months  after  this  he  had  an  attack  of  pneumonia, 
which  left  him  very  weak.  He  then  shipped  on  a  vessel  on  the  lakes  to 
recruit  his  health.  In  July,  while  the  weather  was  very  hot,  he  was  in 
the  habit  of  bathing  every  night.  On  the  night  of  July  26,  after  coming 
out  of  the  water,  he  was  seized  with  a  chill,  and  this  was  followed  by 
fever.  The  fever  lasted  three  days.  On  the  third  day  he  had  intense 
pain  in  the  sacrum,  but  there  was  no  pain  elsewhere,  and  he  had  no  de- 
lirium. His  back  felt  "  stiff,"  but  he  was  able  to  walk  from  the  wharf 
wrhere  his  ship  was  lying  some  distance  into  the  city.  His  left  leg,  how- 
ever, felt  weak,  and  this  weakness  increased  during  that  day.  For  the 
next  two  days  he  passed  no  urine,  and  the  doctor  in  attendance  tried,  un- 
successfully, to  pass  the  catheter.  After  the  application  of  hot  hops  and 
alcohol,  he  urinated  about  a  quart.  In  the  mean  time  the  weakness  of  the 
leg  increased,  and  by  the  fifth  day  of  the  illness  he  could  not  stir  it.  He 
thinks  that  the  loss  of  power  in  the  arm  began  after  the  leg  had  become 
completely  paralyzed ;  but  it  never  became  entirely  powerless.    The  arm 


382 


S  i  N  k  l  e  K ,  Spinal  Paralysis  of  the  Adult. 


[Oct. 


soon  began  to  regain  power.  He  was  admitted  to  the  Marine  Hospital, 
Cleveland,  and  in  about  five  weeks  from  the  onset  of  the  attack  he  began 
to  walk  on  crutches,  although  there  had  been  no  real  improvement  in  the 
ability  to  move  the  leg.  The  atrophy  of  the  leg  began  at  an  early  date. 
The  arm  regained  its  usual  strength  in  four  months.  After  a  year  he  was 
able  to  discard  his  crutches,  and  to  walk  with  a  cane. 

He  was  admitted  to  the  Infirmary  for  Nervous  Diseases  in  November 
1875,  and  remained  there  until  April,  187G.  While  here  he  improved 
considerably.  He  gained  the  [tower  of  using  the  thigh  muscles,  and  of 
moving  the  toes. 

Present  state  Patient  thinks  he  has  gained  some  general  strength  in 

the  leg.  His  general  health  appears  excellent.  The  left  leg  is  the  only 
part  affected ;  it  is  greatly  atrophied,  and  is  very  cold.  He  can  rotate  the 
limb,  can  flex  and  extend  the  thigh,  can  flex  leg  but  cannot  extend  it, 
can  extend  toes,  has  no  power  to  flex  or  extend  foot ;  there  is  slight  pes 
equinus. 

Electrical  condition.  Secondary  faradic  current. — Anterior  and  pos- 
terior thigh  muscles  of  the  left  leg  respond  to  a  strong  current.  None  of 
the  muscles  below  the  knee  respond  to  the  strongest  current. 

Galvanic  current — Forty  cells,  current  reversed ;  cause  good  move- 
ments in  the  thigh  muscles,  but  muscles  of  leg  respond  only  feebly.  Tlie 
gluteal  muscles  are  not  moved  by  the  faradic  current,  but  fifty  cells  gal- 
vanic current  produce  slight  contractions. 

Measurements  of  legs  : — 

Left  leg  four  inches  below  patella,        9  J  inches. 

Right  "    "       "       "       "  12£  " 

Left  thigh  six  inches  above  patella,  13  j  " 

Right  M      "       «       "        "  17|  " 

The  patient  walks  well  with  the  aid  of  a  cane,  and  can  walk  without 
one.  The  foot  is  thrown  down  with  a  flap  by  a  movement  of  the  thigh. 
There  has  been  no  return  of  the  bladder  trouble. 

Case  IV. — H.  P.  M.,  male,  ret.  23  years.  Has  never  had  syphilis,  and 
has  always  been  temperate  as  to  liquor  and  tobacco,  never  using  the  latter 
at  all.  On  the  10th,  11th,  and  12th  of  October,  1877,  he  was'in  Boston, 
and  the  weather  being  bad  he  was  wet  every  day.  He  returned  home  on 
Saturday  the  loth,  and  on  Monday  the  loth  he  first  felt  stiff  and  sore  in 
the  arms,  and  especially  in  the  bend  of  the  elbows,  as  if  he  had  been 
rowing  hard.  He  ascribed  this  to  having  been  hoisting  an  elevator  in  his 
store  on  the  day  he  returned  home.  On  the  next  day  the  pain  was  in  the 
shoulders,  and  his  arms  felt  weak.  On  the  17th  he  complained  of  a  sharp 
pain  in  the  sciatic  nerve,  shooting  down  to  the  toes ;  the  pain  was  not 
violent,  but  was  marked.  The  day  following  the  pain  in  the  sciatic  was 
less,  but  it  was  in  both  hips  with  occasional  darting  pains  in  the  legs  and 
arms.  On  this  day  he  perceived  loss  of  power  in  the  legs,  so  that  he  went 
up-stairs  with  difficulty.  He  consulted  Dr.  TTeir  Mitchell  at  his  office  on 
this  day,  who  found  great  feebleness  of  the  grip,  and  loss  of  power  in  the 
legs,  but  no  loss  of  electro-muscular  contractility.  The  bladder  and  bowels 
were  in  their  normal  state.  He  was  ordered  potass,  iodid.  gr.  v.,  t.  d..  and 
quinia?  sulph.  gr.  ix  daily.  Lentil  October  22d,  the  weakness  increased 
without  any  other  marked  symptom  except  the  pain  in  the  hips,  the  left 
shoulder,  and  occasional  shooting  pains  down  the  limbs.  There  was  no 
fever  or  chilliness,  nor  had  there  been  since  the  beginning  of  the  trouble. 
On  the  22d,  at  the  request  of  Dr.  Mitchell,  I  took  charge  of  the  case.  He 


1878.]  S  i x  k  l  e  r  ,  Spinal  Paralysis  of  the  Adult.  383 


had  become  so  feeble  that  he  was  confined  to  bed,  and  was  unable  even  to 
turn  over  without  assistance.  With  aid  he  could  get  on  his  feet  and  then 
he  could  walk  readily,  but  he  could  not  raise  himself  up  in  bed.  He  had 
constant  pain  in  the  left  shoulder,  which  was  increased  on  motion,  pain 
in  both  thighs,  and  sharp  shooting  pains  over  the  scalp.  There  was  also 
pain  and  stiffness  in  the  temporo-maxillary  articulations.  There  was  no 
complete  paralysis  in  any  part  of  the  body,  but  the  feebleness  of  muscular 
movement  was  extreme.  There  was  absolutely  no  loss  or  impairment  of 
sensation,  and  no  loss  of  power  of  the  bladder.  The  bowels  had  been 
opened  daily,  but  there  was  slight  difficulty  in  defecation.  The  appetite 
was  good,  but  the  food  "  had  no  taste  ;"  this  was  probably  from  the  iodide. 
He  had  slept  very  badly  the  night  previous.  I  ordered  the  quinia  in- 
creased to  gr.  xii  daily. 

Oct.  23.  He  feels  badly,  and  complains  of  ringing  in  the  ears  from  the 
quinia,  but  there  is  less  neuralgic  pain  in  the  scalp ;  he  scarcely  slept  all 
night  and  was  very  restless.  There  is  slight  facial  paralysis  on  both  sides. 
There  is  inability  to  close  the  eyes  completely,  and  the  lower  lip  hangs  as 
if  swollen.  The  tongue  is  protruded  with  ease.  I  stopped  the  quinia 
and  iodide  and  gave  instead  potassii  bromid.,  gr.  x,  and  vin.  ergot,  f5ss 
every  six  hours.  I  directed  the  shoulders  rubbed  with  lin.  amm.,  and  put 
the  patient  on  nutritious  food,  with  beef-tea,  milk,  and  whiskey  f^ss  three 
times  a  day. 

2±th.  Patient  feels  much  better ;  he  slept  soundly  all  night.  There  is 
no  pain  or  stiffness  in  the  jaws,  but  to-day  the  facial  paralysis  is  complete. 
Emotions  produce  no  impression  whatever  on  the  countenance,  and  the 
eyes  are  constantly  suffused  with  tears.  He  is  unable  to  drink  from  a  cup 
or  tumbler,  unless  he  allows  the  liquid  to  run  back  into  fauces,  when  he 
swallows  readily  and  there  is  no  regurgitation  through  nose.  The  tongue 
movements  are  perfect.  There  is  no  impairment  of  voice.  Sensation  of 
face  normal.  Heading  and  smell  unaffected.  There  is  no  diplopia  nor 
dimness  of  vision ;  the  pupils  are  widely  dilated  and  respond  to  light 
sluggishly.    He  feels  stronger  generally. 

25th.  The  patient  is  upon  a  lounge,  and  is  gaining  strength  ;  walks 
well,  when  helped  to  feet,  and  can  bend  body  forwards.  Grip  about  the 
same.  Facial  paralysis  unchanged.  The  only  pain  he  has  is  in  the  left 
shoulder  and  in  the  thighs,  the  latter  occurring  only  when  he  is  attempting 
to  bend  body  forwards.  The  tongue  is  clean,  the  appetite  excellent,  and 
digestion  perfect. 

27th.  Has  gained  everywhere  except  in  face;  facial  muscles  respond 
readily  to  a  secondary  induced  current,  from  Gaiffe's  induction  machine, 
which  is  painless.  Continue  bromide  and  ergot,  and  use  electricity  to  the 
face. 

31st.  Face  improving ;  can  smile,  frown,  etc.  Right  side  of  face  much 
better  than  left ;  right  arm  and  leg  also  strongest.  Continue  faradization  ; 
stop  bromide  and  ergot ;  give  strych.  gr.  ^th  t.  d. 

Nov.  3.  Face  almost  completely  restored  to  usual  condition ;  he  can 
whistle.  Left  leg  still  weak  ;  in  going  up  stairs  he  cannot  put  left  leg  up 
first  and  raise  body  on  it.  Complains  of  occasional  pain  in  left  wrist  and 
hand,  none  elsewhere. 

\lth.  Face  in  normal  state.  Legs  and  arms  about  stationary;  has  not 
improved  materially  in  grip  or  in  power  of  going  up  stairs  since  last  note. 
Give  strych.  gr.  $^th  t.  d.    Faradize  leg  and  arm  muscles. 

Dec.  11.  Has  gained  greatly.    Can  flex  left  thigh  as  well  as  right;  in 


384 


Sinkler,  Spinal  Paralysis  of  the  Adult. 


[Oct. 


going  up  stairs  "  puts  one  foot  before  other"  in  usual  manner.  Is  always 
better  in  evenings  than  mornings.  In  morning  there  is  no  stiffness  or 
numbness,  but  he  cannot  walk  as  well  or  lift  legs  as  well.  Stop  strych. 
R.  Ext.  ergot,  gr.  iiss  t.  d. 

10th.  Is  better  since  taking  the  ergot.  Is  as  strong  now  in  morning  as 
evening. 

28th.  Improves  steadily  ;  rather  more  slowly  now,  but  still  gains.  Stop 
ergot.    R.  Pil.  quin.  fer.  et  strych.  t.  d. 

June  loth.  Is  perfectly  well.  Has  been  riding  on  horseback  for  past 
two  months,  and  gained  much  muscular  strength.  At  first  had  much  dif- 
ficulty in  mounting  his  horse  on  account  of  weakness  in  left  leg,  but  now 
has  no  trouble. 

In  this  case  the  atrophy  was  not  marked,  although  the  limbs  became 
materially  smaller ;  but  this  was  evidently  due  to  the  fact  that  improve- 
ment so  soon  began. 

Case  V. — C.  R.,  male,  aet.  30,  applied  for  treatment  at  the  Infirmary 
for  Nervous  Diseases  April  9,  1875.  In  September,  1873,  was  taken  ill- 
with  what  his  doctor  called  cerebro-spinal  meningitis.  He  had  high  fever, 
with  violent  headache,  diplopia,  and  slight  delirium.  He  was  at  no  time 
unconscious.  He  had  pain  in  the  back  and  inability  to  move  the  head. 
He  states,  however,  that  he  had  had  the  backache  for  a  year.  There  was 
retention  of  urine  for  twenty-four  hours,  and  he  was  constipated.  The 
diplopia  lasted  only  one  day,  it  and  the  headache  having  disappeared 
after  the  application  of  a  blister  to  the  neck.  On  the  second  day  he  had 
violent  pain  in  the  legs,  and  he  found  on  attempting  to  stand  that  there 
was  loss  of  power  in  them  ;  the  arms  were  unaffected.  There  was  no  loss 
of  sensation  in  the  legs,  but  they  felt  somewhat  numb. 

The  loss  of  power  was  complete  at  first,  and  it  was  not  until  five  or  six 
weeks  that  he  began  to  move  the  toes  of  the  left  foot  and  four  or  five 
months  before  he  could  walk  with  crutches.  When  seen  by  us  at  the 
hospital  both  legs  were  atrophied,  and  he  walked  with  difficulty  on  cratches. 
He  was  unable  to  lift  his  feet  or  legs,  but  had  fair  power  in  the  flexors  of 
the  legs,  so  that  he  could  step  over  obstacles  by  going  over  them  back- 
wards. The  eyes  were  examined  with  the  ophthalmoscope  and  found 
healthy.  The  treatment  prescribed  was  iodide  of  potassium  in  increasing 
doses,  and  faradization  and  massage  of  the  legs.  In  a  short  time  strychnia 
was  added  to  the  treatment. 

In  three  months  he  was  able  to  do  without  crutches  and  walk  with  canes. 
The  extensor  muscles  of  the  legs,  however,  improved  but  little,  and  he  was 
still  unable  to  flex  the  thighs.  The  strength  of  the  limbs  gradually  im- 
proved, and  the  same  treatment,  with  slight  variations,  was  continued  for 
nearly  two  years. 

Aug.  12,  1878.  Re-examined.  Patient  can  walk  without  a  cane,  but 
he  is  still  unable  to  raise  the  thighs  when  sitting,  or  to  extend  the  right 
leg  at  all ;  he  can  extend  the  left  leg  to  a  very  slight  degree.  He  can 
flex  both  feet  and  can  strongly  flex  the  legs.  The  legs  are  considerably 
atrophied — 

The  right  thigh  measures  16  inches. 
"    left      "         "        15f  " 
"    right  leg        "        13J  " 
"    left      "         "        12|  " 


1878.]  S inkle r,  Spinal  Paralysis  of  the  Adult.  385 


Electrical  condition  All  of  the  muscles  of  both  legs,  except  the  ante- 
rior thigh  muscles,  respond  to  a  strong  secondary  induced  current.  The 
thigh  muscles  are  moved  readily  by  a  current  from  twenty -four  cells  of 
Stohrer's  small  constant  current  battery.    Sensation  normal. 

The  patient's  general  health  is  good,  and  he  superintends  a  large  busi- 
ness, which  requires  him  to  be  a  great  deal  on  his  feet. 

Dr.  Seguin1  has  collected  forty-five  cases,  and  has  given  the  disorder  a 
close  and  exhaustive  study.  Dr.  Althaus  published  in  the  April  number 
of  this  Journal  two  cases  with  some  valuable  remarks.  One  or  two  other 
cases  have  also  been  reported. 

Now  all  observers  agree  that  the  anatomical  lesions  of  the  disease  are 
the  same  in  adults  and  in  children.  That  is,  the  disease  is  located  in  the 
anterior  cornua  of  the  spinal  cord,  and  the  nerve-cells  in  this  locality  are 
especially  the  seat  of  the  lesion.  But  the  symptoms  and  progress  of  the 
affection  at  the  two  periods  of  life  are  sufficiently  different  to  warrant  the 
division,  by  some  writers,  into  "  spinal  paralysis  of  adults,"  and  "  spinal 
paralysis  of  infancy." 

I  cannot  but  think  that  there  are  some  anatomical  differences,  which  as 
yet  have  not  been  detected,  but  which  influence  and  produce  the  variations 
of  the  disease  in  adult  life  and  in  childhood. 

Take  for  example  the  distribution  of  the  paralysis.  In  two  of  the  forty- 
five  cases  of  adult  spinal  paralysis  collected  by  Dr.  Seguin,  and  in  one  of 
my  own  five,  there  was  facial  paralysis.  In  over  one  hundred  cases  of 
infantile  spinal  paralysis  which  I  have  seen,  there  was  not  one  in  which 
there  was  any  paralysis  of  the  face,  and  the  only  cases  I  have  seen  reported 
are  those  of  West,2  and  these  I  feel  sure  were  cases  of  peripheral  para- 
lysis of  the  seventh  nerve. 

In  adults  there  is  more  apt  to  be  bladder  palsy,  but  this  is  usually  tran- 
sient. There  is  also  more  disorder  of  sensation  in  these  than  in  children. 
Numbness  and  formication  of  the  extremities  are  common  initial  symp- 
toms in  the  former,  and  anaesthesia  or  hyperaesthesia  are  not  rare. 

In  infancy  the  disease  is  stationary  after  the  retrocession  of  the  paralysis ; 
this  I  believe  is  the  invariable  rule.  While  in  adults  it  not  unfrequently 
occurs  that  the  paralysis  spreads  to  parts  not  originally  involved,  and  in 
some  cases  reported,  death  has  followed  from  extension  of  the  paralysis 
upwards. 

The  causation  at  all  periods  of  life  is  rather  obscure,  but  in  a  large  num- 
ber of  cases  in  grown  persons  exposure  to  cold,  chilling  of  the  surface,  or 
checking  of  some  discharge  seems  to  have  been  the  exciting  cause.  In 
children  it  is  difficult  to  point  out  the  origin  of  the  attack,  unless,  as  I 
have  suggested  in  a  previous  paper,3  the  influence  of  hot  weather  upon  a. 

1  Myelitis  of  the  Anterior  Horns.    New  York,  1877. 
3  Diseases  of  Children. 

3  American  Journal  of  Medical  Sciences,  April,  1875. 
No.  CLII  Oct.  1878.  25 


386 


Sinkler,  Spinal  Paralysis  of  the  Adult.  [Oct. 


teething  child  is  sufficient  to  render  the  system  peculiarly  susceptible  to 

the  disease.1 

The  above-mentioned  facts  lead  me  to  surmise  that  in  adults  the  primary 
lesion  is  a  more  or  less  general  congestion  of  the  cord,  with  myelitis  of  the 
anterior  horns  and  subsequent  degeneration  of  the  ganglionic  cells  ;  while 
in  children  the  cells  of  the  anterior  cornua  and  the  gray  matter  itself  are 
directly  affected  without  so  great  an  extent  of  accompanying  congestion. 
The  great  improvement  which  follows  the  use  of  ergot  in  many  cases  of 
adult  spinal  paralysis  seems  to  further  confirm  this  view. 

The  points  as  to  the  diagnosis  of  the  disease  are  fully  given  in  the  text- 
books, so  I  will  not  dwell  upon  them  except  to  remark  upon  the  resem- 
blance of  spinal  congestion  to  the  affection  under  consideration  in  its  early 
stages.  In  spinal  congestion  the  paralysis  is  never  complete,  there  is  no 
subsequent  atrophy,  and  there  is  more  apt  to  be  loss  of  power  in  the  blad- 
der and  rectum.  Some  of  the  cases  reported  seem  much  like  the  so-called 
<£  acute  ascending  paralysis." 

Dr.  Seguin  considers  a  diagnostic  feature  between  this  disease  and  spi- 
nal paralysis  of  adults  the  fact  that  in  the  latter  there  is  no  respiratory  dis- 
turbance, but  in  one  of  his  own  cases  (Case  XXXII.)  death  occurred 
from  asphyxia. 

Dr.  Hammond  considers  the  two  affections  identical,  and  it  certainly 
seems  impossible  to  make  a  diagnosis  between  them  during  life,  but  in  a 
case  of  acute  ascending  paralysis  reported  by  Desjerine,2  no  trace  of  dis- 
ease could  be  found  in  the  cord  after  death. 

Most  writers  express  a  rather  unfavourable  prognosis,  but  I  am  inclined 
to  believe  that  in  most  cases  a  good  result  can  be  obtained  if  the  patient  is 
seen  early  enough.  In  one  of  the  five  cases  I  have  reported  recovery  took 
place,  and  in  another  the  patient,  although  not  entirely  well,  is  vastly 
better,  and  is  continually  improving,  so  that  I  think  we  may  look  for  com- 
plete restoration  of  the  use  of  his  limbs.  Another  case  had  no  treatment, 
and  in  the  remaining  two,  although  coming  under  treatment  at  a  late 
period,  one  two  years,  and  the  other  eighteen  months  after  the  onset  of  the 
paralysis,  there  was  great  gain. 

The  treatment,  I  think,  should  consist  at  first  in  the  administration  of 
ergot,  combined  with  bromide  of  potassium ;  if  there  are  head  symptoms, 
local  depletion  and  counter-irritation  over  the  spine,  and  later  the  use  of 
iodide  of  potassium  and  strychnia.  Dr.  Althaus  recommends  phospho- 
rated cod-liver  oil.  Electricity  and  massage  are  highly  important  agents, 
but  it  must  be  borne  in  mind  that  too  great  care  cannot  be  observed  in  the 
application  of  these  means,  especially  of  the  former.  Great  harm  is  often 
done  to  a  paralyzed  muscle  by  the  too  prolonged  application  of  electricity. 

1  Out  of  seventy-two  cases  which  I  have  examined  in  regard  to  the  season  of  year  at 
which  the  attack  occurred,  in  sixty-five  the  disease  came  on  between  May  and  October, 
and  in  fifty-two  of  the  sixty-five  in  the  months  of  June,  July,  and  August. 

3  Hamilton  on  Nervous  Diseases,  p.  253. 


1878.] 


Gibney ,  Diagnosis  of  Hip-disease. 


387 


Article  VII. 

The  Diagnosis  of  Hip-Disease.  A  Clinical  Contribution.  By  V.  P. 
Gibney,  A.M.,  M.D.,  House-Surgeon  to  the  Hospital  for  the  Ruptured  and 
Crippled,  New  York. 

If  one  study  in  the  field  of  the  microscope  the  amoeba,  and  make  in  slow 
succession  a  half  dozen  sketches  of  this  elementary  form  of  life,  he  will 
recognize  the  marked  change  in  shape  between  the  first  and  last  sketch ;  so 
if  one  record  the  impressions  a  patient,  with  hip-disease,  for  instance,  gives 
him  at  different  observations,  a  study  of  such  impressions  in  relation  to  one 
another  will  enable  him  truly  to  interpret  the  symptoms,  and  to  give  an 
intelligible  diagnosis.  The  hospital  with  which  I  have  the  honour  to  be 
connected  has  afforded  me  an  excellent  opportunity  for  this  kind  of  syste- 
matic observation,  and  the  evolution  of  disease  thus  studied  in  its  various 
stages  has  proved  so  instructive  that  I  am  persuaded  a  record  of  the  cases 
will  be  of  value  to  the  general  practitioner. 

I.  The  Normal  Course  of  Typical  Cases. 

Case  I  Female,  set.  2-J  years,  seen  first  in  the  out-door  department 

July  26,  1876.  The  child  is  plump  and  hearty  looking,  though  on  walk- 
ing the  right  side  is  favoured,  and  the  mother  asserts  that  there  is  no  pain 
night  or  day.  No  tenderness  on  pressure  at  any  point,  no  change  in  con- 
tour of  the  nates  unless  it  be  in  a  possible  shallowness  of  the  trochanteric 
dimple.  Flexion  and  extension  perfect  and  painless,  as  also  adduction, 
though  when  complete  abduction  is  made  there  is  a  little  resistance  on  the 
part  of  the  adductors  ;  no  atrophy.  During  the  month  of  May  preceding 
the  child  was  thought  to  have  fallen  from  a  crib,  walked  lame  next  day,  and 
this  lameness  has  continued  to  present  time,  without  any  evidence  of  pain. 
In  the  maternal  family  history  there  is  a  phthisical  element.  Our  diagnosis 
lay  between  a  periostitis  near  the  trochanter,  and  a  chronic  articular  osteitis. 
The  treatment  to  be  expectant,  and  this  morning  a  spica  is  applied,  and 
iodine  liniment  ordered. 

Aug.  9.  Limp  still  marked,  toes  inverted  a  little,  nearly  one-half  inch, 
atrophy  of  the  thigh,  no  resistance  to  passive  motion.  An  alterative  tonic 
is  ordered  and  abstinence  from  exertion  enjoined. 

16th.  Lameness  more  marked,  in  fact  child  does  not  care  to  walk  at  all ; 
nates  flattened,  though  there  is  no  pain,  tenderness,  or  muscular  contrac- 
tion.   A  fly  blister,  the  vesicated  surface  to  be  freely  poulticed,  is  ordered. 

28^.  Child  refuses  to  walk ;  had  no  pain  until  the  night  of  the  24th, 
when  she  cried  considerably,  and  this  was  attributed  to  a  strain  that  after- 
noon caused  by  a  forcible  eversion  of  the  limb,  the  foot  being  caught  in  the 
bedclothing  as  the  mother  was  in  the  act  of  turning  the  child  in  bed. 
Since  this  accident  the  patient  has  suffered  more  or  less  ;  still  there  is,  this 
morning,  perfect  motion  at  the  hip-joint  active  or  passive.  The  thigh  re- 
mains one  half  inch  small. 

Sept.  9.  A  little  resistance  to  complete  abduction,  and  child  is  reported 
as  restless  at  night. 

28th.  No  apparent  change. 

Nov.  24.  Movable  tumour  at  the  insertion  of  tensor  vaginae  femoris, 
semi-elastic,  and  about  the  size  of  an  English  walnut.    Rotation  inward  and 


388 


Gibnet,  Diagnosis  of  Hip-disease. 


[Oct. 


flexion  are  easily  made,  but  rotation  outward  and  complete  extension  cannot 
be  made  without  pain. 

Dec.  28.  Little  change  in  condition  of  limb  since  date  of  last  observa- 
tion. During  the  past  month,  however,  there  has  been  some  gastric  de- 
rangement, a  varicella,  and  a  bronchitis,  all  of  which  caused  some  loss  of 
flesh  and  seemed  to  develop  many  signs  of  struma. 

Feb.  1,  1877.  Distinct  fulness  over  crest  of  ilium,  that  on  thigh  having 
increased  a  little  ;  motion  at  joint  limited  in  flexion  beyond  an  angle  of  90°, 
and  also  in  rotation. 

March  31.  Suspicious  prominence  of  spinous  processes  of  the  first  and 
second  lumbar  vertebra?  observed  on  standing,  though  when  extension  is 
made  this  disappears  entirely.  If  child  be  placed  on  the  lap  in  prone  posi- 
tion, and  the  head  and  buttocks  be  pressed  in  the  direction  one  toward  the 
other,  pain  is  complained  of  in  lumbar  region.  The  thigh  is  semi-flexed  on 
pelvis  and  fixed  by  muscular  action.  These  signs  are  observed  with  much 
interest  during  the  spring  and  summer. 

Aug.  13.  General  condition  of  child  indicates  improvement;  there  is  no 
longer  any  spinal  prominence  or  tenderness,  no  fulness  over  iliac  crest. 
The  notes  to  April  1,  1878,  show  a  steady  improvement  in  locomotion,  and 
although  the  tumour  over  upper  portion  of  the  thigh  is  still  present,  there 
is  motion  at  the  joint  over  an  arc  of  25°,  the  limb  is  extensible  to  an  angle 
of  140o,  the  limbs  are  of  equal  length,  there  is  no  pain,  and  the  prospects 
for  a  useful  member  are  flattering. 

II.  An  Irregular  though  not  an  uncommon  Course  of  the  Disease 
Illustrated. 

Case  II  July  20,  1877,  a  boy  aet.  8  years  was  brought  into  the  office, 

and  I  at  once  recognized  him  as  an  old  patient  long  absent.  I,  of  course, 
censured  the  mother  for  neglect,  but  she  was  positive  in  asserting  that  at 
her  last  visit  three  years  ago  the  case  was  pronounced  cured ;  so  on  re- 
ferring to  the  books  I  found  a  record  of  the  diagnosis  April  19,  1873,  as 
"hip-disease,  end  of  first  stage,"  and  a  note  July  18th  same  year  "no 
signs  of  disease."  This  morning  his  left  thigh  is  flexed  on  pelvis  at  an 
angle  of  135°,  is  rotated  outward,  the  limb  in  fact  is  the  typical  position  for 
the  second  stage  of  hip-disease.  He  is  very  lame  :  screams  at  night,  wak- 
ing, as  it  were,  out  of  sleep,  and  in  the  morning  has  no  recollection  of  hav- 
ing suffered  or  screamed  during  the  night.  Refers  the  pain  by  day  to  the 
parts  on  either  side  of  the  patella  ;  there  is  no  swelling  or  tenderness  around 
hip  or  knee,  both  of  which  seem  peculiarly  free  from  disease  so  far  as  exter- 
nal appearances  or  handling  are  concerned.  Flexion  and  abduction  can  be 
made  without  pain  or  resistance,  but  other  motions  are  limited  by  muscular 
action  ;  when  passive  motion  is  made  he  complains  of  pain  at  the  knee. 
There  is  no  spinal  tenderness,  no  angular  deformity,  no  reliable  sign  of 
vertebral  disease.  The  mother  declares  that  the  boy  was  well  and  active 
on  the  15th  inst.,  but  did  not  rest  well  on  the  night  of  the  9th  ;  that  he  was 
out  for  a  long  walk  on  the  12th.  slept  well  that  night,  and  on  rising  in  the 
morning  was  lame,  but  was  free  from  lameness  on  the  14th  and  on  the  loth  ; 
that  all  of  the  present  signs  date  from  the  16th.  Last  winter,  she  reports, 
he  had  very  nearly  the  same  train  of  symptoms  one  day  after  a  storm,  and 
recovered  spontaneously.  The  attack  in  1873  had  lasted  two  or  three 
months  prior  to  his  application  here  for  treatment.  With  the  single  excep- 
tion of  the  transient  lameness  of  last  winter,  just  mentioned,  he  is  reported 
to  have  been  absolutely  free  from  anything  like  hip-disease  since  July, 
1873.    One  year  ago  he  had  pertussis  without  any  recognizable  sequel. 


1878.] 


GibneTj  Diagnosis  of  Hip-disease. 


389 


There  are  nine  children  in  the  family,  and  this,  the  seventh,  is  the  only- 
one  ever  out  of  health,  so  claimed.  He  was  always  considered  a  delicate 
child  prior  to  the  spring  of  1873.  A  severe  dentition  with  an  occasional 
convulsion,  a  series  of  convulsions  when  two  years  of  age,  and  a  scarlatina 
shortly  thereafter,  rubeola  next  in  turn,  make  up  his  personal  history.  He 
is  now  fairly  nourished,  though  the  four  lower  and  two  upper  incisors  are 
distinctly  notched  and  irregular,  while  two  molars  on  the  left  side  have  each 
six  distinct  processes.  The  mother  is  of  a  temperament  markedly  nervous, 
and  her  appearance  forcibly  suggests  struma,  the  maternal  grandfather  died 
of  "rheumatic  gout,"  the  grandmother  of  "apoplexy."  The  father  seems 
healthy,  and  gives  a  good  family  history.  No  specific  taint  is  discovered, 
though  strongly  suspected  in  view  of  the  presence  of  Hutchinson's  teeth  in 
the  child.    Fly  blister,  poultices  to  follow,  ordered  to  dorso-lumbar  spine. 

July  27.  The  deformity  is  much  less,  and  the  boy  feels  better.  A 
fourth  of  a  grain  of  the  extract  of  belladonna  three  times  a  day  is  ordered. 
The  treatment  now  is  directed  to  the  spine  more  as  a  solution  to  the  diag- 
nosis than  as  a  therapeutical  measure.  It  will  be  remembered  that  I 
found  no  spinal  tenderness,  and  hence  I  had  no  good  reason  for  consider- 
ing this  a  spinal  arthropathy. 

Aug.  3.  Mother  calls  to  report  the  child  free  from  pain,  and  the  limb 
perfectly  straight,  unless  after  exertion. 

l\th.  Examined,  and  no  resistance  to  normal  motion  in  any  direction 
found,  except  on  complete  extension.  In  view  of  a  possible  syphilitic 
element  in  the  etiology,  potass,  iodid.  gr.  iv  ter  in  die  is  ordered. 

29th.  Scarcely  any  lameness  perceptible  ;  stands  with  limbs  parallel ; 
contour  of  nates  normal ;  motion  good  in  every  direction,  though,  when 
thigh  is  completely  flexed  on  abdomen,  he  complains  of  pain  at  the  knee. 

Sept.  26.  Flexion  and  extension  to  extreme  limit ;  rotation  inward  to 
extreme  limit  causes  the  boy  to  wince,  though  he  protests  against  feeling 
any  pain.    The  iodide  is  continued. 

Oct.  17.  Complete  relapse,  which  the  father  attributes  to  a  strain  the 
boy  received  last  visit  on  the  way  home.  The  iodide  is  discontinued,  and 
the  belladonna,  in  fourth-grain  doses,  ordered  again.  A  liniment  for  the 
hip  is  likewise  prescribed. 

Nov.  7.  Improving  again  at  same  rate  as  before. 

April  17,  1878.  Is  seen  to-day,  and  the  limb  is  found  again  in  position 
of  second  stage.  The  father  reports  that  in  November  last  he  made  a 
good  recovery  from  that  attack,  and  has  been  straight  and  active  until 
three  weeks  ago,  when  present  relapse  appeared.  There  is  found  also 
to-day,  for  the  first  time,  dorsal  tenderness. 

Case  I.  I  believe  to  be  a  typical  one  of  chronic  hip-disease,  the  history, 
progress,  and  all  corresponding  so  well.  The  second  one  I  report  as  hip- 
disease,  with  relapses.  I  report  this,  however,  with  some  hesitation,  but 
shall  presently  give  two  quite  similar  to  this  ;  one  wherein  the  diagnosis 
was  eventually  fully  confirmed.  I  have  not,  as  yet,  employed  any  anti- 
malarial therapeutics,  because  I  have  failed  to  get  a  history  of  any  reliable 
signs  of  malarial  poisoning.  This  treatment,  however,  shall  be  the  next 
adopted,  because  of  the  locality  in  which  the  patient  resides — Williams- 
burg, Long  Island.  The  two  I  am  now  about  to  record  may  assist  in 
diagnosticating  the  one  under  discussion. 


390 


Gibne y,  Diagnosis  of  Hip-disease. 


[Oct. 


Case  III  Female,  set.  8  years,  admitted  to  hospital  January  3, 1871, 

with  a  poor  family  history,  t.  e.,  a  tubercular  one;  a  personal  history  of 
rubeola  and  pertussis  two  years  prior  to  this  state  ;  a  fall  from  a  balcony 
nine  months  after  the  exanthemata ;  confinement  to  bed  two  weeks  imme- 
diately thereafter  as  a  consequence,  pain  being  referred  to  the  groin;  then 
a  partial  recovery,  so  that  she  was  enabled  to  attend  school,  and  run  about 
without  any  inconvenience,  save  an  occasional  pain  in  the  groin  ;  a  relapse 
six  weeks  ago,  with  severe  pain  in  the  region  aforementioned  aggravated 
at  night,  starting  pains,  etc. 

Her  general  health  has  suffered  very  little  impairment ;  she  walks  de- 
cidedly lame ;  stands  resting  the  bulk  of  her  weight  on  the  left  limb,  the 
right  being  semiflexed  at  the  knee,  the  foot  everted.  The  nates  are  broad- 
ened, fold  lowered,  and  cleft  about  normal ;  tenderness  on  pressure  behind 
trochanter,  and  on  percussion  and  concussion  thereover;  considerable 
prominence  in  this  region ;  pain  complained  of  at  the  knee,  and  also  at  the 
hip  if  flexion  be  attempted.  A  diagnosis  of  hip  disease  is  made,  and  con- 
stitutional treatment  ordered.  From  this  date  to  the  1st  of  December  the 
disease  produced  considerable  suffering,  and  more  or  less  deformity.  Blis- 
ters were  applied  when  the  pain  became  severe,  and  the  case  did  so  well 
that,  by  January  22,  1872,  the  child  was  discharged,  walking  without  any 
lameness  whatever,  deformity  entirely  overcome,  motion  restored  to  the 
normal  arc  in  every  direction,  save  in  complete  flexion.  No  significance 
seems  to  have  been  attached  to  this,  and  a  cure  was  recorded. 

June  4,  1873 — nearly  eighteen  months  later — the  patient  is  readmitted, 
a  relapse  having  recently  occurred,  and  the  disease  is  now  well  advanced 
into  the  second  stage.  The  former  treatment  substantially  is  adopted,  and 
by  the  29th  her  symptoms  all  denote  improvement. 

jVbr.  9.  Suffering  greatly,  and  confined  to  bed.  The  subsequent  notes 
of  the  case  tell  only  of  a  gradual  transition  into  the  third  stage  without  the 
formation  of  abscess,  with  comparatively  little  pain,  with  little  deformity, 
but  with  the  usual  amount  of  shortening  and  lameness.  By  January  7, 
1876,  this  stage  is  reached,  the  limb  is  one  inch  short,  two  and  one-half 
inches  small  at  the  thigh,  though  not  in  any  angular  deformity,  and  withal 
very  serviceable.  Three  or  four  attacks  of  pain,  neuralgic  in  character, 
have  occurred  since  this  last  note,  but  the  disease  is  long  since  arrested, 
the  patient  discharged,  and  walking  with  very  slight  inconvenience. 

Case  IV — Hip-disease,  first  stage,  apparent  Care;  relapse  at  the  end 

of  three  years  and  three  months;  Death  from  Adenia  ;  Autopsy  Male, 

set.  4  years;  admitted  to  the  hospital  March  29,  1871.  Family  history 
not  obtained  with  any  degree  of  completeness,  the  only  notes  found  re- 
corded are  that  the  mother  is  dead,  and  that  the  patient  has  a  brother 
afflicted  with  hip-disease,  third  stage,  and  grave  in  character.  It  is  also 
rcorded  that  this  child  fell  from  a  velocipede  about  one  year  prior  to  his 
admission,  and  a  few  months  later  complained  of  pain  in  the  right  knee. 
This  became  severe,  and  was  referred  to  the  hip,  causing  the  usual  night 
screams,  the  morning  stiffness,  etc. 

Condition  on  entrance  to  hospital  as  follows:  plump,  and  well  nourished; 
boy  standing  with  the  right  lower  extremity  semiflexed,  everted,  and 
resting  on  the  toes,  and  walking  with  a  very  marked  limp ;  nates  on  right 
side  broadened,  natural  depressions  effaced,  fold  raised,  and  cleft  inclined 
to  the  left;  thigh  flexed  on  pelvis  at  an  angle  of  150°,  and  held  here  by 
muscular  action,  though  flexion  can  be  carried  to  90°  without  causing 


1878.] 


Gibney,  Diagnosis  of  Hip-disease. 


391 


much  pain.  The  diagnosis  is  made  without  reservation,  and,  under  the 
usual  treatment  of  the  hospital,  the  case  made  good  progress;  though  in 
the  month  of  May  there  occurs,  without  known  cause,  a  suppurative 
middle-ear  disease,  left  side. 

Sept.  8.  It  is  noted  that  his  condition  is  such  as  to  justify  his  discharge. 

Oct.  6.  General  health  seems  excellent ;  he  stands  squarely  on  both 
feet,  and  walks  without  a  trace  of  lameness  ;  no  atrophy  exists,  no  tender- 
ness or  pain  on  complete  flexion  or  extension,  or  on  concussion  of  tro- 
chanter— in  fact,  no  sign  of  disease  in  or  about  the  hip  can  be  detected. 
His  friends  had  deserted  him,  and  no  home  could  be  found;  hence  he  re- 
mained in  the  hospital,  different  persons  promising  to  adopt  him,  until  the 
beginning  of  1875.  During  that  period  never  a  sign  of  disease  was  ob- 
served, and  the  cure  was  regarded  as  well  established.  The  ear  disease 
continued,  however,  after  the  usual  manner. 

January  1,  1875.  Note  is  made  of  an  enlargement  of  cervical  glands 
right  side  three  months'  standing,  coming  on  without  any  known  cause, 
and  steadily  gaining  ground  despite  all  treatment.  Hip  still  free  from  any 
sign  of  disease. 

2d.  After  perfect  immunity  for  three  years  and  three  months,  the 
hip  is  the  seat  of  great  pain,  and  the  boy  is  abed  with  a  high  temperature, 
and  crying  if  any  motion  at  the  joint  be  attempted.  Fly  blisters  and 
poultices. 

lQth.  Acute  symptoms  relieved,  and  the  boy  going  around  the  ward, 
though  joint  still  tender  and  glandular  infiltration  increasing.  A  general 
glandular  enlargement,  or  adenia,  set  in,  the  boy  became  emaciated  to  a 
skeleton,  and  death  by  asthenia  occurred  February  28. 

Autopsy  twenty-four  hours  later,  conducted  by  Dr.  Edward  G.  Jane- 
way,  pathologist  to  the  hospital.  Body  greatly  emaciated,  and  skin  jaun- 
diced about  eyes,  scrotum  and  right  lower  extremity ;  both  lower  limbs 
lie  in  complete  extension,  and  motion  at  joints  is  free. 

Right  lung  slightly  (edematous,  otherwise  normal,  and  old  pleuritic  ad- 
hesions are  extensive  ;  left  lung  and  pluera  normal,  as  also  the  heart. 
Peritoneal  cavity  contains  about  a  pint  of  a  yellowish  jelly-like  material ; 
liver  is  one-fourth  larger  than  normal,  and  on  the  surface  as  well  as  on 
section  there  is  a  mottled  appearance. 

In  the  gastro-hepatic  omentum  a  gland  the  size  of  a  walnut  presses 
against  the  ductus  communis  choledochus,  the  pyloric  orifice  of  the  stomach 
and  the  receptaculum  chyli.  The  microscopic  appearances  of  this  gland 
are  normal.  Mesenteric  glands  enlarged,  as  likewise  the  cervical,  from 
the  mastoid  process  to  the  clavicle,  varying  in  size  from  a  hazel-nut  to  a 
walnut.  A  deeper  gland  separates  the  deep  jugular  from  the  carotid,  a 
space  of  one  inch,  and  presses  against  the  pneumogastric.  Pus  is  found 
in  the  right  middle  ear,  extending  into  the  mastoid  cells. 

The  right  hip-joint  being  opened,  the  capsular  ligament  is  found  intact, 
there  is  no  fluid  within  the  cavity,  and  suction  force  is  normal,  while  the 
ligamentum  teres  is  easily  detached.  Head  of  bone  presents  a  dirty  yel- 
lowish aspect,  with  a  groove  extending  from  ligamentum  teres  towards 
trochanter  minor,  intersecting  a  similar  groove  about  the  insertion  of  cap- 
sular ligament.  In  this  groove  is  new  connective  tissue.  At  one  point 
the  cartilage  is  completely  eroded ;  head  flattened.  On  vertical  section 
there  appear  three  yellowish  spots,  two  above  and  one  below  the  line  of 
epiphysial  union,  which  line  of  union  is  carried  up  one  inch  ;  cartilage 
is  one-half  the  normal  thickness,  and  this,  as  well  as  the  bone  underlying, 


392 


Gibney,  Diagnosis  of  Hip-disease. 


[Oct. 


is,  in  the  field  of  the  microscope,  seen  to  be  in  the  process  of  fatty  degen- 
eration. The  head  and  neck  of  the  sound  femur  are  also  removed,  and  the 
above  description  is  comparative.  Blood  examined  microscopically,  and 
found  normal. 

The  accompanying  cuts  show  very  strikingly  the  pathological  changes, 
with  the  exception  of  the  colouring. 

The  whitish  spots  in  the  head  and  neck  of  Fig.  l,in  the  original  sketch 
as  made  by  an  artist  at  the  post-mortem,  are  yellowish,  showing  the  fatty 
metamorphosis  to  perfection.  Fig.  2  is  the  sound  bone,  and  is  inserted 
for  comparison. 


Fig.  1.  Fig.  2. 


The  two  cases  just  recorded  illustrate:  1,  the  insidious  mode  of  inva- 
sion; 2,  the  behaviour  of  the  disease  when  the  general  health  is  improved, 
and  the  patient  placed  under  a  favourable  hygiene ;  3,  the  remissions,  or 
periods  of  apparent  recovery,  lasting  even  three  and  one-fourth  years  ;  4, 
given  the  diathesis,  the  ease  with  which  the  disease  can  be  induced  on  the 
slightest  provocation ;  5,  the  dominant  tendency  of  hip-disease  to  progress 
unimpeded  through  the  three  stages.  Case  IV.  illustrates  the  pathology, 
viz.,  a  central  osteitis  extending  to  the  periphery,  and  ultimately  destroy- 
ing the  joint  structures.  With  cases  III.  and  IV.  in  mind,  I  feel,  in  a 
measure,  justified  in  assuming  case  II.  to  be  one  of  chronic  hip-disease. 

III.  Cases  Illustrative  of  Acute  Synovitis  of  the  Hip-joint. 

Case  V — On  the  19th  of  February,  1874,  a  fair-haired  German  girl, 
set.  6  years,  was  brought  into  the  office,  and  the  pain  suffered  by  the  child 
was  so  intense  that  it  was  with  the  greatest  difficulty  an  examination  could 
be  made,  in  fact  this  was  deferred  until  the  patient  could  be  gotten  into 


1878.] 


G ibney ,  Diagnosis  of  Hip-disease. 


393 


the  ward,  and  in  the  mean  time  a  history  was  obtained.  The  family  was 
found  healthy  and  free  from  disease  ;  the  girl  herself  was  an  only  child, 
and  had  always  enjoyed  excellent  health.  She  was  considered  perfect  in 
health  and  limb  on  the  evening  of  the  16th  instant — three  days  ago — 
went  to  bed  in  that  condition,  and  was  awakened  suddenly  during  the 
night  by  acute  pain  referred  to  the  right  hip-joint.  Her  screams  alarmed 
the  household.  Febrile  movement  was  marked,  and  in  the  morning  the 
child  was  unable  to  stand  on  the  limb  at  all.  The  pain  and  tenderness 
seemed  to  increase,  and  the  loss  of  strength  from  sleeplessness  and  general 
constitutional  disturbance  soon  became  alarming. 

On  examination  this  evening  the  tongue  is  coated,  the  patient  cannot  be 
induced  to  stand  alone,  much  less  to  take  a  step,  and  after  much  persuasion 
she  allows  herself  to  be  held  in  the  standing  posture,  when  the  right  lower 
extremity  is  suddenly  adducted,  advanced,  and  semi -flexed ;  little  or  no 
change  has  taken  place  in  the  nates,  there  is  no  atrophy  of  the  limb,  and 
no  shortening.  Any  attempt  at  active  or  passive  motion  causes  intense 
pain  at  the  hip,  though  by  grasping  the  thigh  carefully  and  firmly,  making 
traction  the  while,  the  muscles  hitherto  in  tonic  rigidity  gradually  relax, 
and  a  great  sense  of  relief  is  experienced.  Acute  synovitis  of  the  hip  is 
diagnosticated,  and  a  fly  blister  applied  to-night. 

March  1.  Almost  entirely  free  from  pain,  and  condition  is  much  im- 
proved. 

21st.  A  second  blister  applied  on  recurrence  of  pain.  From  this  time 
forward  the  case  progressed  as  favourably  as  could  have  been  desired,  and 
on  October  21  it  is  recorded  that  little  or  no  deformity  exists  ;  the  child 
walks  with  comparative  facility.  An  examination  is  made  August  4, 
1875,  no  unfavourable  symptom  having  occurred  in  the  mean  time,  and  the 
result  is  as  follows  :  general  health  robust ;  stands  with  right  limb  slightly 
advanced,  walks  and  runs  freely,  though  favouring  this  side  ;  contour  of  hip 
almost  perfectly  restored ;  flexion,  extension,  ab-  and  adduction  easily  ac- 
complished ;  no  pain  or  tenderness,  no  shortening  or  atrophy  ;  with  the 
exception  of  a  mere  limp  the  cure  is  perfect.  This  lameness  must  be  due 
to  some  loss  of  substance  in  the  joint  structures — a  theory  very  plausible 
in  view  of  the  severity  of  the  primary  lesion.  The  girl  was  seen  by  me 
a  year  or  so  later,  and  this  limp  could  scarcely  be  detected. 

Case  VI — A  boy,  9  years  of  age,  is  carried  into  the  waiting  rooms  of 
the  out-door  department  August  29,  1873.  He  screams  and  raves  like  a 
mad-man,  so  intense  is  his  suffering.  His  nervous  system  seems  at  the 
point  of  exhaustion.  The  sight  is  a  pitiable  one,  and  one  that  I  shall 
never  forget.  His  immediate  admission  to  the  hospital  is  advised,  and 
gladly  acceded  to.  It  is  learned  that  about  four  weeks  ago  a  lameness 
came  on  suddenly,  and  without  apparent  cause.  This  seemed  at  the  time 
trifling,  and  only  until  within  a  few  days  ago  did  the  acute  symptoms  super- 
vene. The  family  history  furnishes  nothing  important.  The  boy  is  thin,  and 
poorly  nourished,  haggard  looking,  his  tongue  is  heavily  coated ;  with  much 
difficulty  and  much  pain  he  stands  alone,  though  only  for  a  few  moments  ; 
is  totally  unable  to  walk.  Thorax,  abdomen,  and  spinal  column  examined, 
with  negative  results.  Right  nates  very  much  enlarged,  fold  obliterated  ; 
tumefaction  around  the  hip  is  very  great,  and  the  temperature  of  the  parts 
is  perceptibly  elevated ;  position  of  limb  advanced,  semiflexed  and  everted. 
Tenderness  in  groin  and  around  trochanter  well  marked ;  movement  of  the 
limb  not  tolerated ;  no  atrophy  or  shortening.  Over  the  nates  is  an  ex- 
coriated surface,  the  result  of  some  recent  vesicant.    To  this  surface  a 


394 


Gibney,  Diagnosis  of  Hip-disease. 


[Oct. 


poultice  is  applied,  and  this  is  to  be  renewed  every  six  hours  for  two  or 
three  days. 

Sept.  5.  Six  days  after  admission — all  the  acute  symptoms  have  sub- 
sided, and  the  patient  is  able  to  stand,  and  even  walk  a  few  steps  alone. 

Oct.  2.  A  most  marked  improvement  has  taken  place  ;  scarcely  a  sign 
of  disease  remains  about  the  hip  ;  walks  with  a  very  slight  degee  of  lame- 
ness, and  he  is  to  all  appearances  cured. 

Dec.  12.  Health  in  fine  condition;  boy  stands  squarely  on  both  feet, 
walks  and  runs  freely,  no  limp  whatever  being  present ;  normal  contour  of 
nates  restored ;  no  tenderness  on  rough  handling.  Patient  discharged 
cured.  Up  to  May  1,  1878,  I  am  credibly  informed,  no  signs  of  relapse 
have  ever  appeared. 

Case  VII — Male,  aet.  9  years,  admitted  to  hospital  September  5,1877. 
Fairly  nourished,  though  there  is  evidence  of  slight  febrile  movement  in 
the  frequency  of  the  pulse,  120,  and  in  the  temperature,  101^°.  Stands 
with  left  thigh  advanced,  knee  semiflexed,  and  foot  everted  a  little;  unable 
to  walk  without  great  pain  ;  nates  enlarged,  and  presenting  a  sense  of  elas- 
ticity to  the  touch ;  the  parts  are  tender,  while  the  surface  temperature  is 
two  degrees  lower  than  at  a  corresponding  point  on  the  opposite  side. 
Muscles  unusually  tense,  and  groin  very  tender;  extension  beyond  150° 
and  flexion  beyond  90°  are  painful,  though  pressure  of  the  limb  upward 
toward  the  acetabulum  elicits  no  pain.  No  spinal  tenderness,  no  ilio-costal 
fulness,  no  tenderness  or  induration  in  the  iliac  fossa.  Paternal  and  mater- 
nal family  histories  good  so  far  as  can  be  learned,  and  the  boy's  own  history 
shows  excellent  health  from  infancy  to  date  of  present  disease,  which  seems 
to  have  resulted  from  a  fall  into  a  cellar,  August  18th,  seventeen  days  ago, 
as  he  was  lame  next  day,  though  the  acute  symptoms  are  only  of  two  days' 
standing.  The  diagnosis  is  held  in  reserve  for  a  few  days,  and  the  case 
treated  as  if  one  of  hip  disease. 

Sept.  15.  Patient  has  grown  steadily  worse,  and  it  is  with  great  difficulty 
he  can  be  moved;  effusion  about  hip  increasing;  circumference  upper  one- 
fourth  16|  inches,  middle  third  9  inches,  and  at  same  points  fellow  limb 
12f  and  7  inches;  blistering  has  afforded  no  relief. 

20th.  Confined  to  bed  since  date  of  last  note,  screaming  with  pain  all 
through  the  night  unless  under  the  influence  of  opiates.  His  decubitus  is 
prone,  constitutional  disturbance  great.  There  seems  to  be  no  doubt  as  to 
the  diagnosis  now — acute  coxo-femoral  synovitis  with  impending  suppura- 
tion. Full  doses  of  the  tincture  of  the  chloride  of  iron  and  chlorate  of 
potassa  are  given  in  glycerine,  while  evaporating  lotions  are  kept  continu- 
ously to  the  hip. 

22c?.  Measurements  at  same  points  as  above  recorded,  right  side,  18  and 
13^  inches,  while  the  circumference  just  above  the  knee  is  10J  inches, 
showing  the  extent  of  the  infiltration  throughout  the  thigh.  An  abscess  of 
enormous  size  has  formed,  throwing  the  thigh  in  great  deformity,  and  re- 
ducing the  boy  to  a  condition  of  great  emaciation. 

Oct.  1.  An  incision  is  made  giving  exit  to  at  least  two  pints  of  pus  of 
good  consistence.    Tonics  and  stimulants  administered  unsparingly. 

2d.  Improvement  \  ery  marked. 

4th.  Sitting  up  to-day,  and  free  from  pain. 

17^.  Wound  has  healed;  limb  gaining  strength  daily,  and  boy  now 
walking  about  by  the  aid  of  a  chair. 

Nov.  10.  Has  regained  flesh;  hip  is  in  a  good  condition;  contour  of 
nates  restored;  boy  walks  and  runs  with  only  a  slight  halt  perceptible. 


1878.]  Gibney,  Diagnosis  of  Hip-disease.  395 


Dec.  8.  Discharged  cured.  No  deformity;  no  resistance  to  normal 
motions  to  full  extent ;  no  difference  in  size  of  limbs ;  no  lameness. 

IV.  The  Difficulty  of  making  a  differential  Diagnosis  between  Infantile 
Spinal  Paralysis  in  the  first  stage  and  Hip-disease  in  its  first  stage. 

Occasionally  the  early  signs  of  hip-disease  correspond  so  closely  with 
those  of  infantile  paralysis  that  a  differential  diagnosis  is  by  no  means  easy. 
One  would  think  it  an  easy  matter  to  diagnosticate  a  paralysis,  yet  such 
is  not  always  the  case.  If  the  child  be  only  recently  ailing,  if  fretfulness 
and  hyperesthesia  be  present,  if  there  be  a  history  of  a  fall  or  other  injury 
(the  easiest  part  by  all  odds  of  the  history  to  get),  the  case  becomes  very 
obscure.    Take  as  illustration  the  following. 

Case  VIII  A  male  child,  agt.  2  years,  was  brought  to  the  office  Sept. 

16th,  1874,  for  examination.  He  was  healthy  in  appearance,  but  was  a 
little  peevish.  As  he  stood  in  a  state  of  nudity,  the  left  natis  was  observed 
to  be  flattened  a  little,  and  the  fold  was  lowered.  Pressure  over  the  tro- 
chanter elicited  tenderness,  and  the  least  passive  motion  of  the  limb  caused 
the  child  to  cry  out  as  if  in  pain.  Measurement  gave  only  a  shade  of 
atrophy.  The  skin  felt  cold,  and  the  surface  thermometer  indicated  a 
slight  diminution  in  temperature.  There  was  lameness,  but  as  the  child 
walked  one  could  see  that  this  was  not  due  to  the  action  of  muscles  in 
protecting  the  hip;  the  gait  was  unsteady;  a  tottering  at  the  knee  was 
observed,  and  after  going  a  few  steps  the  limb  gave  way,  and  a  fall  was 
the  result.  The  electrical  examination  was  unsatisfactory,  though  there 
seemed  to  be  a  diminution  in  the  force  of  the  faradic  contractions.  The 
mother,  in  giving  the  history,  stated  that  seven  nights  ago,  without  any 
provocation,  so  far  as  she  knew,  the  child  became  a  little  peevish  and  rested 
badly ;  slept  late,  however,  the  morning  following,  and  walked  on  rising ; 
but  that  after  a  few  hours  she  noticed  the  child  fall,  get  up  again,  and  after 
awhile  fall  again ;  that  he  cried  and  moaned  the  second  night,  crying  the 
more  if  the  left  limb  was  moved ;  that  he  was  very  lame  on  the  second 
day;  that  she  took  him  to  a  surgeon  of  acknowledged  ability — a  man 
whose  diagnosis  it  would  be  arrogance  to  question ;  that  after  a  long  ex- 
amination she  was  told  a  hip-splint  must  be  procured  as  early  as  possible ; 
that  she  could  not  meet  the  expense  of  the  apparatus,  and  that  she  comes 
here  now  two  days  later  hoping  to  get  the  needed  splint  free  of  charge.  In 
the  family  history  a  maternal  aunt  is  reported  to  have  died  of  hydrocepha- 
lus at  the  age  of  eleven  years.  The  history  of  the  invasion,  the  unsteadi- 
ness of  gait,  the  age  of  the  child,  suggested  to  my  mind  a  paralysis  of  a 
group  of  muscles  of  the  limb,  and  to  this  diagnosis  I  adhered  especially 
after  an  examination  on  the  day  following.  Santonine  was  prescribed  in 
order  to  remove  any  causes  acting  reflexly  in  the  intestinal  canal.  No  re- 
sults were  obtained  from  this,  and  after  one  or  two  more  visits  the  child 
was  lost  sight  of  for  nearly  a  year,  when  the  mother  brought  him  back 
to  be  treated  for  a  calcaneo-valgus  paralytic  in  origin.  Apparatus  was 
applied,  and  electricity,  both  currents,  used  two  or  three  times  a  week. 
The  patient  has  attended  irregularly,  but  has  worn  a  brace  constantly. 
April  20,  1878,  there  is  one-half  inch  atrophy  of  thigh  and  of  calf,  the  foot 
is  one-half  inch  short,  is  in  valgo-calcaneous,  though  easily  held  in  normal, 
position.  The  reaction  of  the  muscles  on  posterior  surface  of  leg  to  fara- 
dism  is  abolished,  to  galvanism  is  almost  normal. 


396 


G  i  b  n  e  y  ,  Diagnosis  of  Hip-disease. 


[Oct. 


Case  IX  Female,  set.  2  years,  presented  in  out-door  department  Oct. 

3,  1877.  Reported  as  having  been  seized  with  a  slight  febrile  attack  five 
weeks  ago.  This  continued  five  days,  and  at  night  the  child  was  worse. 
During  that  period,  and  for  a  week  later,  the  child  refused  to  walk,  and, 
if  placed  on  feet,  would  cry  as  if  in  severe  pain.  Gradually  improved  for 
a  week,  but  for  the  past  two  weeks  the  improvement  has  been  less  marked. 
Latterly  has  had  no  pain  whatever  even  when  walking  freely.  Patient 
seen  twice  during  the  fourth  week  by  a  surgeon  whom  the  profession  re- 
gards as  an  expert  in  this  specialty,  and  this  gentleman  writes  that,  after 
careful  examinations,  he  locates  the  disease  within  the  hip-joint,  as  he  finds 
unmistakable  muscular  rigidity  about  the  hip.  He  makes  a  differential 
diagnosis,  however,  from  infantile  paralysis.  This  morning  the  nates  on 
left  side  is  flattened  perceptibly,  the  calf  is  one-half  inch  small,  motion  at 
the  hip-joint  is  made  to  the  normal  extent  in  all  directions  without  pain, 
though  there  seems  to  be  a  little  resistance  to  complete  abduction  ;  there 
is  marked  diminution  of  the  tibialis  anticus  in  reaction  to  the  faradic 
current.  There  is  lameness,  but  this  is  not  like  that  due  to  disease  of  the 
joint.  Our  diagnosis  is  infantile  spinal  paralysis  confined  to  a  single 
muscle  or  group  of  muscles,  and  treatment  instituted  therefor.  There  is 
now,  April  22,  1878,  a  slight  degree  of  varus,  the  limb  feels  colder  than 
its  fellow,  there  is  atrophy,  and  the  child  becomes  lame  after  moderate 
exertion — tires  easily.  Neither  has  now,  nor  has  had  since  October,  any 
pain  whatever,  diurnal  or  nocturnal,  and  the  limb  can  be  handled  without 
any  discomfort.  My  friend,  Dr.  Horst,  of  the  hospital,  has  just  visited 
the  little  patient,  and  examined  carefully  for  any  muscular  rigidity  on 
active  or  passive  motion,  finding  none.  He  verifies  the  diagnosis  of 
paralysis. 

The  case  I  am  now  to  report  was  first  diagnosticated  by  me  as  infantile 
paralysis,  and,  after  a  few  examinations,  I  recognized  my  error,  changing 
completely  the  diagnosis. 

Case  X  A  buxom,  hearty-looking  female  child,  set.  4^-  years.  Came 

under  observation  for  the  first  time  in  the  outdoor  department  April  10, 
1877.  The  gait  suggested  an  incipient  hip  disease,  yet  the  history  and 
the  facts  elicited  by  examination  seemed  to  point  unerringly  to  a  slight 
stroke  of  acute  spinal  paralysis.  The  aunt  who  accompanied  the  child — 
a  very  intelligent  woman — states  that  one  week  ago  nothing  whatever 
could  be  discovered ;  that  a  change  was  made  in  the  stockings — from  long 
to  short  ones — at  that  time ;  and  that,  while  the  little  girl  was  out  play- 
ing, she  complained  of  pain  along  the  outer  side  of  the  right  leg,  the  limb 
became  tender  to  handling,  and  felt  much  colder  than  its  fellow.  The 
patient  is  examined  in  a  state  of  nudity  this  morning.  No  change  in  the 
nates  can  be  discovered ;  no  resistance  to  motion,  active  or  passive,  at  the 
hip  in  any  normal  direction  or  extent ;  the  limb  is  perceptibly  colder  than 
the  other,  and,  by  the  surface  thermometer,  is  1°  lower;  there  is  no 
atrophy  of  the  thigh,  but  the  calf  and  the  ankle  are  one-fourth  of  an  inch 
small,  though  the  reaction  to  both  currents  is  normal.  There  has  been 
no  screaming  at  night.  The  family  history  would  lead  one  to  incline  to 
joint  disease,  though,  as  there  is  a  history  of  no  starting  pains  at  night,  as 
the  muscles  present,  no  contraction,  however  slight,  and  as  any  amount  of 
handling  elicits  no  tenderness  at  the  joint,  disease  here  is  excluded.  The 
treatment  is  expectant. 


1878.] 


Gibney,  Diagnosis  of  Hip-disease. 


397 


April  17.  The  lameness  is  not  so  marked,  though  the  temperature  of 
the  limb  is  1  \°  lower  than  its  fellow  ;  electrical  reactions  still  normal. 

26th.  Temperature  same  on  both  sides;  calf  one-fourth  inch  small; 
nothing  else  observable  save  the  limp. 

May  16.  Walks  this  morning  as  if  the  hip  were  surely  the  seat  of  dis- 
ease ;  there  is  tenderness  on  deep  pressure  in  the  groin ;  thigh  can  be  ex- 
tended freely,  but,  when  flexion  is  attempted,  this  movement  is  not  perfect 
— the  limb  rolls  outward  a  little.  The  child  complains  of  fatigue  towards 
evening,  though  she  sleeps  well,  with  the  exception  of  occasional  moaning. 
Circumference  of  the  two  thighs  at  upper  and  middle  thirds  is  the  same, 
but  at  lower  third  that  of  right  is  one-fourth  inch  less  ;  calf  and  ankle  are 
now  one-half  inch  small,  while  the  foot  is  one-fourth  inch  short.  Hip  dis- 
ease is  diagnosticated  now,  and  treatment  begun  therefor.  The  condition 
on  June  27  is  less  like  hip  disease  than  at  last  visit.  The  child  has  been 
resting  well  at  night ;  motion  at  joint  is  good — almost  perfect. 

July  30.  Patient  lies  on  back  this  morning,  as  requested,  and  volun- 
tarily flexes  thigh  through  the  normal  arc.  The  notes  to  Sept.  1  indicate  an 
almost  complete  subsidence  of  disease,  but  on  this  date  a  slight  degree  of 
fulness  is  observed  at  the  insertion  of  the  tensor  vaginas  femoris,  the  limb 
at  this  point  being  one-half  inch  larger  than  the  other.  Motion  is  limited 
in  complete  extension,  not  otherwise.  .  A  periostitis  immediately  suggests 
itself,  and  the  resistance  to  extension  is  easily  explained. 

Sept.  22.  Motion  at  joint  not  so  free  as  on  the  1st.  The  disease  is  still 
regarded,  however,  as  one  of  periostitis. 

It  can  be  readily  seen  how  a  paralysis  affecting  a  single  group  of  mus- 
cles may  give  rise  to  signs  almost  pathognomonic  of  hip  disease.  The 
case  just  reported  gave  a  history,  it  is  true,  very  much  like  that  of  infan- 
tile paralysis,  though  not  a  typical  history,  and  "  type  cases"  are  so  rare 
that  I  was  easily  led  into  error  by  remembering  this  fact,  and  by  the 
trophic  changes  so  early  observed.  Still  the  child  was  beyond  the  age  at 
which  the  majority  of  spinal  paralyses  occur,  and  this  fact  should  have 
commanded  more  respect.  Furthermore,  the  preservation  of  faradic 
irritability  could  just  as  well,  according  to  some  recent  observations,  ex- 
clude incipient  arthropathy  as  spinal  paralysis. 

V.  Spinal  Arthropathy  affecting  the  Hip-joint  as  differentiated  from 
Hip -disease. 

True  and  false  arthropathies  of  spinal  origin  may  likewise  be  interpreted 
as  true  joint  disease,  though  the  hip  is  not  so  often  the  seat  of  these  neu- 
roses as  are  the  knee  and  ankle  joints.  Still,  in  my  experience,  the  hip 
has  been  sufficiently  affected  to  cause  some  errors  in  diagnosis,  and  the 
following  case  is  presented  as  illustrative  : — 

Case  XI  A  strumous-looking  female  child,  set.  10  years,  admitted  to 

hospital  April  21,  1876.  The  family  history  is  imperfectly  obtained,  as 
no  other  members  are  present  at  date  of  admission,  the  child  coming  from 
an  orphan  asylum.  A  history  of  the  exanthemata  is  obtained  however, 
and  of  a  fall  from  a  bed  six  or  eight  weeks  prior  to  this  date,  and  the 
appearance  of  signs  pointing  to  some  lesion  about  the  hip  two  weeks  there- 
after.   This,  taken  in  connection  with  her  general  appearance,  a  marked 


398 


G  i  b  N  e  t  ,  Diagnosis  of  Hip-disease. 


[Oct. 


lameness  typical  of  hip-disease,  the  position  of  the  right  limb  in  standing, 
viz.,  in  semiflexion,  eversion,  and  rotation  outward ;  a  flattening  of  the 
nates,  tenderness  on  pressure  thereabout  amounting  to  a  hyperesthesia ; 
resistance  to  flexion  beyond  90°,  to  extension  beyond  160°;  a  swelling 
near  the  crest  of  the  ilium  ;  an  absence  of  real  shortening,  while  there  is 
an  apparent  shortening — the  above  history,  I  say,  taken  in  connection  with 
all  these  signs,  positive  and  negative,  leads  to  a  diagnosis  of  hip-disease 
second  stage  ;  though,  on  reflection,  it  occurs  to  us  that  such  an  amount 
of  hyperesthesia  cannot  be  due  to  disease  in  the  hip-joint,  and  that  such 
deformity  has  come  on  too  soon  for  true  joint  disease,  and  hence  we  placed 
an  interrogation  point  after  the  diagnosis  already  recorded.  The  treat- 
ment to  be  expectant. 

May  9.  A  distinct  and  well-marked  fulness  over  crest  of  right  ilium, 
from  anterior  superior  spinous  process  to  sacro-iliac  junction,  quite  tender 
to  pressure.    The  hip-joint  seems  free  of  any  trouble. 

1  '2th.  Fulness  slowly  increasing,  a  fly  blister  is  applied  this  evening,  the 
usual  poulticing  to  follow. 

l'bth.  Abed  this  forenoon,  but  this  afternoon  moves  about  the  ward  with 
great  difficulty  by  aid  of  a  chair,  the  foot  being  raised  some  two  inches 
from  the  floor.  The  symptoms  gradually  subsided,  and  with  the  exception 
of  a  pain  in  the  lumbar  region  at  times,  nothing  occurred  until  August  17, 
when  the  fulness  seemed  to  have  shifted  from  the  ilium  to  the  thigh,  and 
the  upper  fourth  of  this  member  measured  one  inch  more  in  circumference 
than  the  left.  There  accompanied  this  heat  tenderness  and  constitutional 
disturbance  generally.  A  cathartic,  evaporating  lotion,  and  rest  seemed 
to  afford  relief  by  the  26th,  though  the  fulness  remained.  "With  a  few 
intervening  notes  of  minor  importance,  it  is  noted  on  September  28,  that 
the  child  stands  with  both  limbs  parallel,  and  scarcely  a  limp  can  be 
detected  in  her  gait.  The  changes  subsequent  to  this  depended  on  the 
amount  of  exercise,  and  the  treatment  was  purely  expectant.  At  times, 
she  was  in  great  pain,  unable  to  leave  her  bed,  and  the  parts  around  the 
hip  were  exquisitely  sensitive,  then  relief  would  come  and  she  would  get 
almost  well. 

May  29,  1877.  In  one  of  these  attacks  there  is  discovered  marked  ten- 
derness over  and  to  either  side  of  the  spinous  processes  from  the  fifth 
dorsal  vertebra  to  the  sacrum.  The  spine  is  thoroughly  blistered  and 
poulticed,  with  decided  benefit.  Subsequently,  ergot  was  administered,  and 
by  July  20  there  is  no  pain  or  lameness  or  other  sign  of  disease.  She  is 
kept  under  daily  observation  until  October  5,  up  to  which  time  not  an 
untoward  symptom  has  recurred,  and  now  she  is  discharged  cured ;  no 
muscular  rigidity,  no  tenderness — spinal  or  femoral — and  no  lameness 
whatever  existing. 

Further  cases  may  be  found  detailed  in  a  paper  read  by  the  author 
at  the  session  of  the  American  Neurological  Association  in  June,  1877. 
entitled,  "  Spinal  Irritation  in  Children  as  related  to  True  and  False 
Arthropathies."  The  paper  is  in  the  Transactions  of  the  Association  for 
that  year.  A  case  presented  January  4,  of  present  year,  with  very  promi- 
nent signs  of  disease  at  the  hip-joint,  but  the  gait  of  the  child  alone  saved 
us  from  committing  an  error  in  diagnosis.  Talipes  equinus  of  cerebral 
origin  was  made  out,  and  this  proved  to  be  one  of  the  prodromata  of  a 
tubercular  meningitis.    The  case  is  so  interesting  that  I  am  strongly 


1878.] 


Gibxey,  Diagnosis  of  Hip-disease. 


399 


tempted  to  report  it  in  this  connection,  but  already  my  paper  is  becoming 
unwieldy  on  account  of  its  length. 

"While  on  this  subject  of  neuroses,  I  take  occasion  to  refer  to  cases  of 
intestinal  irritation  from  Ascaris  lumbricoides,  which  presented  almost 
complete  pictures  of  hip-disease. 

VI.  Caries  of  the  Lumbar  Vertebrce  in  the  first  stage,  or  in  the  advanced 
stages,  often  simulates  Hip-disease.    As  illustrations  the  following — 

Case  XII. — January  28,  1877,  a  Scotchwoman  brought  her  boy,  aet. 
2-|  years,  into  the  office  for  examination.  The  little  fellow  was  plump 
and  hearty-looking,  but  exceedingly  cross,  and  a  thorough  examination 
was  very  difficult ;  still,  it  was  observed  that  he  stood  in  a  semi-stooped 
position,  with  right  thigh  advanced  and  knee  a  trifle  flexed,  that  he  walked 
with  a  kind  of  hop,  the  shoulders  being  elevated,  that  he  stooped  without 
bending  the  spinal  column,  the  motion  being  made  (and  that  cautiously, 
too)  at  the  hips  and  knees,  that  in  the  dorsal  decubitus  complete  extension 
of  the  right  thigh  could  not  be  made  without  tilting  the  pelvis,  while  the 
other  movements  could  be  made  easily  and  painlessly,  that  in  prone  posi- 
tion the  spinous  processes  of  the  last  dorsal  and  the  first  lumbar  vertebrae 
seemed  a  little  prominent,  no  tenderness  on  pressure  or  percussion  being 
present.  The  history  was  that  two  weeks  previously  he  was  perfectly 
well  and  had  been  up  to  that  time,  that  shortly  thereafter  he  complained 
of  an  occasional  pricking  sensation  in  the  right  lower  extremity,  no 
febrile  movement  accompanying  ;  that  for  a  week  he  had  been  restless  at 
nights,  complaining  of  pain  when  handled,  and  had  been  lying  across  the 
mother's  lap  for  ease.  The  father  was  rheumatic,  the  mother  healthy,  so 
reported. 

A  diagnosis  of  caries  of  the  spine  was  made,  the  contraction  of  the 
thigh  flexors  being  accounted  for  by  the  relationship  between  the  seat  of 
lesion  and  the  origin  of  the  muscles  in  question.  Measure  taken  for  a 
brace. 

February  14.  Fulness  over  crest  of  right  ilium  this  morning  with  an 
elevation  of  temperature,  as  shown  by  the  thermoscope.  Contraction  of 
psoas  so  great  that  thigh  cannot  be  extended  beyond  130°.  Fly  blister  to 
region  of  fulness. 

29th.  Thigh  held  flexed  at  an  angle  of  90°  ;  fulness  over  crest  still  a 
prominent  feature.  A  more  thorough  examination  is  made  and  negative 
points  noted,  but  transcription  here  unnecessary. 

March  18.  Little  change  as  yet,  and  as  the  boy  is  recently  complaining 
of  abdominal  pains  the  spinal  brace  is  applied,  and,  at  the  same  time,  a 
gentle  counter-irritant  is  ordered  to  the  spine. 

June  23.  A  mere  trace  of  contraction  of  psoas  remains,  the  boy  stands 
with  limbs  straight  and  walks  with  a  very  slight  limp.  With  a  few  unim- 
portant changes  he  did  well,  and  his  condition,  as  recorded  August  16,  is 
that  his  health  is  apparently  excellent ;  right  thigh  advanced  a  little,  but 
extensible  to  extreme  limit  with  moderate  force,  a  distinct  incurvation  of 
spine,  from  the  tenth  dorsal  to  the  third  lumbar,  with  a  shade  of  fulness 
over  sacrum.  The  mother  has  unadvisedly  left  off  the  brace  a  few  nights 
and  the  boy  seems  to  have  suffered  from  this  as  an  effect. 

Sept.  5.  Caries  of  lumbar  spine  indubitable,  as  a  prominence  is  percep- 
tible. 


400 


G  i  b  n  e  y  ,  Diagnosis  of  Hip-disease. 


[Oct. 


Nov.  13.  Induration  and  swelling  in  the  right  groin,  the  ganglia  here 
being  infiltrated.  Circumference  of  the  thigh,  upper  fourth,  one  inch 
greater  than  its  fellow. 

l<6th.  Case  seen  by  a  well-known  clinical  professor,  who  has  no  diffi- 
culty in  making  a  correct  diagnosis,  but  requests  the  privilege  of  bringing 
the  boy  before  his  class  in  order  to  illustrate  the  points  in  differential  diag- 
nosis between  the  second  stage  of  morbus  coxarius  and  femoral  abscess  of 
spinal  origin.  The  subsequent  history  bears  only  on  the  progress  of  the 
case,  and,  in  brief,  is  simply  the  formation  of  a  large  residual  abscess, 
opened  by  aspiration  May  18,  1877;  relief  in  due  time;  an  almost  perfect 
recovery  by  the  close  of  July,  and  death  from  malignant  scarlatina  August 
3,  with  no  opportunity  for  an  autopsy. 

A  physician  is  called  in  sometimes  to  see  a  child  with  a  swelling  about 
the  hip ;  this  is  examined  superficially  on  account  of  the  prominent  signs ; 
a  history  is  sought ;  the  fall  is  described,  and  his  diagnosis  is  unhesitatingly 
made  without  having  his  attention  drawn  to  the  spinal  column.  To  my 
own  knowledge  this  has  occurred  time  and  again.  As  an  instance  the  fol- 
lowing : — 

Case  XIII  In  the  early  part  of  January  of  present  year  a  mother 

called  to  report  her  child,  an  out-patient  of  the  hospital,  as  unable  to  attend, 
so  helpless  had  he  become  by  reason  of  the  progress  of  the  disease.  She 
mentioned  the  name  of  her  family  physician,  whom  I  knew  to  be  thoroughly 
competent,  from  his  surgical  experience  in  some  of  the  best  hospitals  in  the 
city,  to  take  charge  of  any  case,  and  to  him  I  referred  this  patient,  a  boy, 
set.  11  years,  under  our  treatment  since  March  5,  1874,  for  caries  of  the 
lower  dorsal.  When  I  last  saw  the  boy  in  August,  1877,  there  was  a  cir- 
cumscribed tumour  over  the  left  hip,  and  I  recognized  this  as  a  spinal 
abscess,  ordering  appropriate  treatment  therefor.  1  instructed  the  mother 
to  ask  the  physician  to  whom  I  had  just  referred  the  case,  to  notify  me  as 
to  present  condition. 

Jan.  17.  I  was  informed  by  letter  that  the  child  with  caries  of  the  spine 
had  also  hip-joint  disease  of  over  a  year's  standing,  received  from  a  fall ; 
that  the  leg  was  flexed  somewhat  upon  the  thigh,  and  the  thigh  upon  the 
abdomen,  the  usual  position  of  the  limb.  I  immediately  requested  a  con- 
sultation, but  the  Doctor  was  called  out  of  town,  and  left  word  for  me  to 
examine  at  my  convenience. 

30^.  I  made  a  careful  examination,  and  found  a  marked  angular  de- 
formity of  the  spine,  a  soft,  fluctuating  tumour  over  upper  and  outer  aspect 
of  thigh,  measuring  three  inches  vertically,  and  an  inch  and  a  half  trans- 
versely. The  circumference  of  the  limb  at  every  point  save  over  this  tumour 
was  identical  with  that  of  the  other  limb ;  there  was  no  shortening  what- 
ever, and  the  thigh  could  be  moved  in  every  direction  without  any  pain  in 
the  hip  or  at  the  knee ;  but  when  complete  extension  was  made,  the  skin 
covering  the  tumour  was  put  on  stretch,  and  the  boy  complained  of  pain 
here.  Rotation  was  easily  accomplished,  and  I  could  find  no  disease  at  the 
hip  by  any  of  the  recognized  signs.  In  the  absence  of  shortening,  atrophy, 
and  muscular  contractions  about  the  hip  limiting  motion,  and  in  view  of 
the  position  of  the  limb,  I  could  not  make  out  any  hip-joint  disease,  and  so 
reported  to  my  friend  the  physician. 


1878.] 


Gibxey,  Diagnosis  of  Hip-disease. 


401 


VII.  Extra-capsidar  Abscess  may  be  so  situated,  and  so  Clironic  in 
Character,  that  a  Differential  Diagnosis  from  Hip-disease  becomes  very 
difficult. 

Muscular  function  may  be  impeded  by  abscess  having  no  connection 
with  the  joint ;  the  limb  may  become  distorted,  and  errors  in  diagnosis 
may  easily  occur.  A  child  in  robust  health  may  get  a  contusion,  and  from 
this  a  circumscribed  cellulitis  may  arise,  and  suppuration  may  result ;  or 
a  child,  in  a  low  condition  of  health,  may  get  what  is  termed  a  "cold  ab- 
scess" in  the  neighbourhood  of  the  hip,  and  this  may  last  indefinitely. 

Case  XIV. — Female,  a?t.  3  years,  to  all  appearances  well  nourished, 
was  admitted  to  the  hospital  December  14,  1875.  The  father  and  mother 
gave  good  family  histories,  while  the  child  herself  was  reported  as  having 
enjoyed  peculiar  immunity  from  the  diseases  of  infancy.  Began  to  walk 
lame  one  year  prior  to  admission,  and  no  cause  could  be  assigned.  This 
was  the  only  sign  observed  until  within  the  last  few  weeks,  when  pain 
was  complained  of  in  the  back,  and  this  pain  was  increased  by  any  jar  or 
turning.  The  child  was  restless  and  wakeful  at  night.  About  one  month 
ago  a  plaster  of  Paris  jacket  was  applied  by  a  physician  for  suspected 
spinal  disease.  This  proved  very  uncomfortable,  and,  failing  to  give  sup- 
port to  which  the  child  could  accustom  itself,  was  removed  by  the  mother, 
without  consulting  the  physician,  at  the  end  of  two  weeks,  when  a  swell- 
ing was  observed  over  the  left  hip. 

This  morning  the  child  stands  with  left  limb  advanced,  toes  slightly  in- 
verted, and  walks  quite  lame.  The  spinal  column  presents  no  deviation 
laterally  or  antero-posteriorly,  and  no  tenderness  on  pressure,  percussion, 
or  concussion.  The  left  nates  is  broader  than  its  fellow,  fold  elongated. 
Above  the  trochanter,  and  extending  from  the  same  to  the  crest  of  the 
ilium,  is  a  circumscribed  fulness,  elastic  to  the  touch,  non-fluctuating,  and 
painless  on  pressure.  Thigh  can  be  flexed  to  an  angle  of  90°  without 
pain,  and  can  be  completely  extended,  though  there  is  muscular  resistance 
to  complete  abduction.  There  is  no  shortening,  no  atrophy  of  the  limb, 
and  no  tenderness  can  be  elicited  at  the  sacro-iliac  juncture.  The  diag- 
nosis is  not  positive,  although  hip-disease  suspected.  Treatment  expectant, 
a  compress  with  the  roller  being  applied  over  the  tumour  for  the  present. 

Jan.  25,  1876.  The  gluteal  tumour  is  perceptibly  smaller,  and  the  child 
walks  with  more  ease. 

26th.  Nurse  reports  that  the  patient  complains  of  pain  along  the  spine, 
but  a  thorough  examination  to-day  is  attended  with  negative  results. 

March  28.  The  tumour  has  extended  below  the  gluteal  fold ;  general 
health  very  good. 

April  16.  Immediately  to  the  left  of  the  sacro-iliac  synchondrosis  is  a 
hardish  movable  tumour,  the  size  of  a  half-walnut ;  over  the  upper  extre- 
mity of  the  thigh  on  a  line  with  the  fold  of  nates  is  a  tumour  larger  in  size, 
fluctuating,  and  painless. 

May  20.  Both  tumours  have  increased  in  size,  and  the  veins  thereover 
are  prominent. 

June  16.  Incision  at  most  dependent  portion  gives  exit  to  about  one 
pint  of  pus,  of  fair  consistence. 

'28th.  Constitutional  disturbance  only  within  past  three  days,  and  patient 
r  ow  very  feeble  and  indisposed  to  eat  or  make  any  exertion.  The  dis- 
charge has  been  very  profuse  and  offensive.  Brandy  and  tonics  given 
No.  CLII  Oct.  1878.  26 


402 


Gibney,  Diagnosis  of  Hip-disease. 


[Oct. 


freely,  while  the  usual  disinfecting  injections  are  used.  The  notes  from 
this  time  forward  show  a  steady  decline  ;  emaciation  became  extreme,  and 
all  efforts,  nutrient  and  stimulant,  proved  unavailing.  Finally  an  ex- 
haustive diarrhoea  set  in  ;  this  was  followed  by  a  dysentery,  and  on  August 
23,  five  days  after  the  diarrhoea  began,  the  patient  died  by  asthenia. 

An  examination,  post-mortem,  revealed  the  sac  of  an  abscess  about 
eight  inches  long  by  four  wide,  lying  between  the  glutei  muscles,  and  a 
careful  search  failed  most  signally  to  detect  any  connection  with  diseased 
bone.  The  hip-joint,  the  sacro-iliac  joint,  and  the  dorso-lumbar  vertebrae 
were  carefully  examined  and  found  to  be  absolutely  free  from  disease. 

The  locality  of  this  abscess  enhances  the  interest  of  the  case,  in  view  of 
the  presumptive  evidence  at  different  periods  of  lumbar  caries,  sacro-iliac 
disease,  and  hip  disease. 

A  suppurative  inflammation  of  the  lymphatic  ganglia  in  the  inguinal 
region  may  give  rise  to  signs  which,  under  certain  circumstances,  could 
baffle  the  skill  of  a  very  clever  diagnostician. 

Case  XV. — Female,  set.  5  years,  admitted  to  the  hospital  July  24, 
187G.  A  history  of  the  exanthemata  was  obtained  with  very  clear  signs 
of  sequelae,  unless  the  appearance  of  present  ailment,  in  April,  could  be 
construed  into  a  sequel  of  a  diphtheria  (?)  which  occurred  in  the  month  of 
December  preceding.  The  father  and  mother  seemed  healthy,  and  no 
cause,  either  predisposing  or  exciting,  could  be  assigned  for  present  train 
of  symptoms.  In  April,  as  just  intimated,  a  swelling  appeared  in  left 
groin,  and  a  lameness  was  observed  about  the  same  time.  This  wras  all 
that  was  learned  from  the  mother. 

The  child  on  admission  is  anaemic,  stands  with  left  limb  a  little  advanced, 
and  walks  favouring  this  limb.  In  the  dorsal  decubitus,  the  spinous  pro- 
cesses on  a  horizontal  plane,  the  popliteal  space  cannot  be  brought  nearer 
than  three  inches  to  the  floor ;  flexion  can  be  made  over  normal  arc,  and 
ab-  and  adduction  easily  accomplished.  The  thigh  is  one-half  inch  smaller 
than  its  fellow.  In  the  left  groin,  about  midway  of  Poupart's  ligament,  is 
an  indolent  ulcer  three-quarters  of  an  inch  long  by  one  inch  wide,  edges 
smooth  ;  one  inch  below  this  is  a  still  smaller  ulcer,  in  the  bottom  of  which 
is  a  little  pus.  Suppurative  lymphadenitis  diagnosticated,  and  the  treat- 
ment consisted  of  simple  dressings,  an  alterative  tonic,  with  cod-liver  oil. 

These  ulcers  proved  very  obstinate,  and  did  not  thoroughly  heal  until 
the  following  March.  She  did  not  gain  sufficient  strength,  howrever,  to 
warrant  her  removal  from  treatment  ;  but  on  April  27,  five  weeks  after  the 
closing  of  the  ulcers,  the  child  was  discharged  cured,  there  being  no  halt 
whatever  in  her  gait. 

VIII.  Perinephritis  in  Children  gives  rise  to  Signs  often  Diagnostic 
of  Hip -disease. 

About  one  year  ago  I  published  in  this  Journal  three  cases  of  perine- 
phritis, and  in  the  American  Journal  of  Obstetrics  and  Diseases  of  Wo- 
men and  Children,  the  year  before,  nine  cases,  and  in  many  of  these  the 
symptoms  and  signs  so  clearly  resembled  those  of  the  disease  now  under 
consideration  that  I  could  not  refrain  from  dwelling  at  some  length  on  this 
very  subject.    Since  my  last  publication,  four  or  five  new  cases  have  been 


1878.] 


Gib  net,  Diagnosis  of  Hip-disease. 


403 


under  observation  at  the  hospital,  and  from  that  number  I  select  the  fol- 
lowing by  way  of  illustration. 

Case  XVI. — May  10,  1877,  a  mother  brought  her  boy,  a?t.  12  years, 
into  the  office  for  treatment,  and  he  was  admitted  to  the  hospital  the  same 
day.  With  the  exception  of  one  or  two  of  the  diseases  of  infancy  he  had 
enjoyed  good  health.  The  father  had  been  a  drunkard,  and  had  died 
phthisical  ;  a  paternal  aunt  had  died  of  hip-disease  ;  the  mother  gave  a 
rheumatic  history.  The  disease  for  which  the  boy  is  now  admitted  was 
first  manifest  six  weeks  ago,  supposably  originating  in  a  "  cold."  Loss  of 
flesh  had  been  marked,  and  his  appearance  to-day  is  indicative  of  much  recent 
suffering.  Pulse  116,  R.  28,  T.  101  j°.  He  stands  with  body  inclined  to 
the  right,  the  lower  extremity  of  this  side  slightly  flexed  at  hip  and.  knee. 
The  spinal  column  deviates  to  the  same  side,  though  there  is  no  tenderness 
along  the  column,  no  angular  curvature,  no  pain  on  per-  or  concussion  ;  the 
nates  is  broadened.  Lameness  is  marked,  and  very  like  to  that  of  a  patient 
with  hip-disease,  second  stage.  The  thigh  cannot  be  extended  beyond  an 
angle  of  1G5°  without  pain,  but  can  be  flexed  and  rotated  over  normal  arcs. 
Measurements  of  the  two  limbs  identical.  He  complains  of  pain  about  the 
knee.  In  the  left  lumbar  region  the  erector-spinal  muscle  is  full  and  tense, 
giving  quite  a  ridge-like  prominence  ;  yet  there  is  no  pain  here,  or  in  the 
right  ilio-costal  space  ;  two  and  one-half  inches  from  the  spinous  processes 
of  the  vertebrae  there  is  marked  tenderness,  which  extends  to  the  right  in  a 
horizontal  plane  to  a  point  immediately  above  the  anterior  superior  spinous 
process,  where  the  tenderness  becomes  more  extensive  in  area.  This  area 
is  triangular,  extending  along  Poupart's  ligament.  There  is  subintegu- 
mentary  induration  along  and  above  the  ligament,  with  extra  heat  and 
comparative  dulness.  Flexion  of  thigh  relieves  pain.  There  is  and  has 
been  no  intestinal  derangement.  Suffice  it  to  say,  we  had  no  difficulty  in 
diagnosticating  a  perinephritis.  The  progress  of  the  case  differed  from 
usual  type.  Suppuration  came  on  in  due  time,  a  large  abscess  being 
opened  just  above  Poupart's  ligament. 

June  15.  The  sac  was  washed  out  with  a  solution  of  carbolic  acid  twice 
daily,  and  by  July  10  the  wound  had  about  closed,  and  the  boy  was  nearly 
well.  A  relapse  occurred  at  this  time,  the  sac  filled  again,  and  the  boy 
became  very  lame. 

July  28.  The  pus  has  burrowed  beneath  the  superficial  abdominal  fascia, 
from  pelvis  to  lumbar  spine,  and  hectic  is  marked.  The  medication  thus 
far  had  been  the  tincture  of  the  chloride  of  iron  and  chlorate  of  potassa, 
with  stimulants,  p.  r.  n. 

Aug.  4.  All  acute  symptoms  have  subsided ;  the  discharge  is  simply  an 
oozing,  and  the  patient  otherwise  might  be  considered  as  cured. 

9^.  Wound  entirely  closed. 

24^.  Boy  fat  and  hearty ;  active  in  body  and  limb  ;  walks  and  runs 
without  any  lameness  ;  cured. 

IX.  Rheumatism  of  the  Hip-joint  as  differing  from  Hip-disease. 

A  monarticular  rheumatism  affecting  the  hip  is  not  of  common  occur- 
rence in  children,  and  hence  we  are  not  often  called  upon  to  exclude  this 
in  making  up  a  diagnosis.  Still  cases  do  occur,  and  with  more  frequency 
probably  than  we  are  willing  to  admit.  There  is  good  reason  for  supposing 
that  many  of  those  cases  of  hip-disease  wherein  a  cure  has  taken  place  in 
the  second  stage  have  been  nothing  more  than  a  chronic  monarticular 


404 


Gib  net,  Diagnosis  of  Hip-disease. 


[Oct. 


rheumatism.  While  I  have  seen  a  few  cases  undoubtedly  rheumatic  in 
nature,  I  have  not  kept  full  notes  throughout  the  various  stages ;  but  the 
following  case,  which  came  under  observation  in  the  out-door  department, 

may  serve  as  an  illustration  : — 

Case  XVII — Female,  net.  17  years.  March  27,  1876.  Hearty  and 
robust ;  walks  very  lame,  though  with  comparative  ease.  Left  hip  anchy- 
losed  at  an  angle  of  125°,  being  in  strong  adduction  as  well  as  flexion. 
There  is  much  lordosis;  the  limb  is  shortened  nearly  1^  inches,  appa- 
rently 4  inches.  Xo  swelling,  pain,  or  tenderness.  Atrophy  of  thigh  3 
inches,  of  calf  \  inch.  Patient  had  scarlatina  when  three  years  of  age, 
and  one  year  later  the  disease  which  has  left  her  deformed  first  made  its 
appearance.  She  had  much  pain  at  first  ;  was  confined  to  bed  a  long  time ; 
never  had  any  abscess,  or  any  sign  of  one.  A  brother,  set.  9,  had  just 
been  in  the  hospital  for  chronic  rheumatic  arthritis  of  the  knee,  with  pains 
about  the  hip.  Knee  swelled  at  time  of  admission,  and  lesion  was  located 
in  this  joint.  One  month  later  the  right  ankle  became  painful  and  swelled. 
This  soon  subsided,  and  five  weeks  later  the  right  shoulder  was  affected, 
and  recovered  in  one  month. 

I  cite  this  boy's  case  as  suggestive  at  least  of  a  rheumatic  diathesis  in 
the  family,  and  as  evidence  that  the  case  of  his  sister  is  one  of  rheumatism. 

X.  Does  Malaria  effect  the  Hip-joint  or  Surroundings,  causing  Signs 
and  Symjjtoms  of  Hip-disease  ? 

It  is  a  fact  that  physicians  who  practise  in  malarial  districts  often  meet 
with  patients  presenting  many  of  the  signs  of  hip-disease  ;  that  they  put 
these  same  patients  on  full  doses  of  quinia,  and  all  other  signs  of  arthro- 
pathy disappear. 

The  case  I  am  now  to  report  was  referred  to  the  hospital  by  Dr. 
Mcllroy,  of  this  city. 

Case  XYIII — Female,  one  year  and  two  months  of  age,  seen  Febru- 
ary 20,  1877.  The  child  seemed  fairly  nourished,  though  that  which 
seemed  the  most  prominent  sign  was  its  refusal  to  put  the  left  foot  to  the 
floor,  when  held  up.  The  limb  is  semiflexed  at  the  hip  and  knee,  and 
rotated  outwards  ;  nates  flattened,  though  no  fulness  here,  and  no  other 
evidence  of  effusion ;  head  of  thigh-bone  rotated  with  ease,  though  when 
complete  extension  was  attempted  there  was  resistance  on  the  part  of  the 
psoas  and  iliacus,  and  the  adductors  were  moderately  tense  as  well.  The 
limb  was  held  with  exceeding  care  by  the  little  patient.  Rectal  tempera- 
ture 101°.  The  child  very  cross  and  the  mother  very  silly,  hence  a 
thoroughly  satisfactory  examination  impracticable. 

A  history  of  "  a  cold  in  the  head"  for  two  weeks,  accompanied  during 
the  past  four  days  with  an  intermittent  fever,  so  far  as  can  be  learned  from 
the  mother's  description.  Had  a  fall  from  a  chair  on  the  2d  inst.,  striking 
on  the  back,  no  immediate  injury  being  observed.  Just  began  walking  on 
the  8th,  and  eight  days  later  refused  to  walk,  the  intermittent  fever  coming 
on  at  this  time.  The  parents  lived  in  the  upper  part  of  Xew  York,  be- 
yond the  Harlem  River — a  locality  abounding  in  malaria.  The  diagnosis 
was  obscure,  and  I  wrote  Dr.  Mcllroy  a  note  advising  the  use  of  quinia 
in  full  doses,  thinking,  at  least,  that  at  the  next  visit  the  symptoms  would 
be  much  clearer. 


1878.] 


Bull,  Syphilis  of  the  Conjunctiva. 


405 


March  5.  Dr.  M.  has  been  giving  quinia  daily  since  last  visit,  with  the 
effect  of  ameliorating  the  malarial  element.  This  morning  there  is  decided 
induration  around  the  lower  third  of  the  femur,  with  contraction  of  the  leg- 
flexors  ;  three-fourths  inch  larger  than  fellow.  A  brace  is  applied  to 
overcome  the  contraction. 

April  6.  Mother  calls  this  morning  bringing  child  in  one  hand  and  the 
brace  in  the  other.  She  calls  to  report  a  cure  and  return  the  brace.  The 
child  walks  well,  and  lias  no  pain.  Examination  fails  to  detect  anything 
save  a  crackling  sensation  when  passive  motion  is  made  at  the  knee,  and 
this  seems  due  to  a  dryness  of  the  synovial  membrane.  No  difference  in 
size,  no  pain  of  any  kind.  Fourteen  days  ago  the  intermittent  fever  was 
broken  up,  and  all  the  joint  signs  disappeared  with  this.  Dr.  M.  writes 
me  recently  that  to  his  knowledge  no  relapse  has  ever  occurred. 

It  will  be  seen  from  a  careful  study  of  the  cases  herein  recorded  that  no 
one  sign  or  symptom  is  pathognomonic  of  hip-disease. 

It  is  dime ult  to  lay  down  rules  by  which  a  diagnosis  can  always  be  easily 
made.  I  know  of  no  better  method  than  a  thorough  examination  of  the 
patient,  testing  the  functions  of  the  limbs,  being  at  the  same  time  familiar 
with  the  normal  functions.  The  history  must,  of  course,  be  as  accurately 
obtained  as  possible  ;  and,  if  a  slow  insidious  beginning  can  be  distinctly 
traced,  then  the  evidence  becomes  strong.  Frequent  observation  must  be 
made  when  there  is  room  for  doubt.  I  believe  it  well  that  cases  wherein 
much  doubt  exists  should  be  treated  as  hip-disease  until  the  signs  are  suffi- 
ciently clear  to  make  a  diagnosis.  The  child  should  have  the  benefit  of 
the  doubt. 


Article  YIII. 

Syphilis  of  the  Conjunctiva.   By  Charles  Stedmax  Bull,  A.M.,  M.D., 
Surgeon  to  the  Xew  York  Eye  Infirmary  and  to  Charity  Hospital,  New  York. 

Syphilitic  lesions  of  the  conjunctiva,  existing  independently,  and  not 
connected  with  lesions  of  the  eyelids  on  the  one  hand,  or  of  the  eyeball  on 
the  other,  are  not  common.  The  connection  between  the  palpebral  con- 
junctiva and  the  other  structures  of  the  eyelids  is  so  intricate,  that  syphi- 
litic infiltration  of  the  lid,  be  it  circumscribed  or  diffuse,  soon  involves  the 
mucous  membrane.  The  same  may  be  said,  in  a  modified  sense,  of  the 
connection  between  the  ocular  conjunctiva  and  the  underlying  fibrous  cap- 
sule of  the  eyeball. 

In  syphilitic  patients  we  not  unfrequently  meet  with  an  obstinate  con- 
junctival inflammation  of  the  catarrhal  type,  without  there  being  any 
certainty  that  the  conjunctivitis  is  caused  by  the  syphilis.  This  is  espe- 
cially noticeable  in  some  cases  of  obstinate  iritis. 

The  older  authors  were  very  apt  to  confound  syphilitic  lesions  of  the 
conjunctiva  with  those  of  the  lids,  not  recognizing  any  difference  in  their 


40G 


Bull,  Syphilis  of  the  Conjunctiva. 


[Oct. 


course,  or  in  their  place  of  origin.  Even  Lawrence,  who  usually  discrim- 
inated accurately,  is  not  always  clear  upon  this  point.  He  admits  that  the 
mucous  lining  of  the  eyelids  sometimes  participates  in  the  syphilitic  erup- 
tions which  affect  the  general  cutaneous  surface,  and  is  right  in  believing 
that  this  does  not  happen  so  often  as  we  might  have  been  led  to  expect 
from  observing  the  correspondence  in  diseased  action  between  the  conjunc- 
tiva and  the  skin. 

As  a  matter  of  clinical  experience  it  may  be  stated  that  the  syphilitic 

lesions  of  the  conjunctiva  are  eruptions,  ulcerations,  and  infiltrations. 

Under  the  head  of  ulceration  are  to  be  considered  the  chancre  or  initial 

lesion  of  syphilis,  and  secondary  ulcers,  resulting  from  the  breaking  down 

of  infiltrated  masses.    All  modern  authorities  ajjree  in  recognizing  the 

©  ©  © 

occurrence  of  the  initial  lesion  upon  the  conjunctiva,  as  well  as  gummy 
infiltrations  and  secondary  ulceration.  Mauthner  and  Bouchet  both  speak 
of  the  occurrence  of  soft  chancres  in  the  conjunctiva,  but  it  is  not  quite 
clear  what  they  mean  by  the  term. 

The  initial  lesion  is  rarely  met  with  on  the  eyelids,  and  is  a  still  rarer 
occurrence  on  the  conjunctival  surface  alone.  In  most  of  the  reported 
cases  the  ulcer  has  been  on  the  margins  of  the  lids,  where  cutaneous  and 
conjunctival  surfaces  meet.  Cullerier,  Mackenzie,  Lawrence,  Ricord, 
Fournier,  Martin,  and  others,  all  speak  of  chancres  in  this  locality.  Ac- 
cording to  Sturgis,  in  his  report  of  1646  tabulated  cases  of  chancre,  the 
ulcer  occurred  only  six  times  on  the  eyelid.  But  in  some  of  the  cases 
reported,  the  ulcer  was  purely  a  conjunctival  lesion.  Desmarres  (Mala- 
dies des  Yeux,  ii.,  p.  213)  mentions  a  case  of  chancre  of  the  conjunctiva, 
occurring  in  a  woman,  near  the  inner  canthus,  and  occupying  the  entire 
thickness  of  the  upper  lid.  The  ulcer  was  deep,  with  sharp  edges,  its  bot- 
tom was  covered  by  a  gray  pultaceous  matter,  and  there  was  engorgement 
of  the  neighbouring  lymphatic  glands.  Seven  weeks  later  appeared  a 
general  papular  syphilide.    The  ulcer  healed  on  the  sixtieth  day. 

Mauthner  quotes  another  case  of  Desmarres,  in  which,  in  the  middle  of 
the  inferior  conjunctival  cul-de-sac,  there  was  an  oval  tumour  as  large  as  a 
pea,  firmly  connected  with  the  mucous  membrane,  with  ulcerated  surface, 
and  eroded  Avails,  and  enlarged  preauricular  gland.  The  diagnosis  of 
chancre  was  confirmed  by  Ricord.  Mauthner  also  saw  in  a  girl,  in  the 
conjunctiva  of  the  left  lower  lid,  an  ovoid,  smooth  tumour,  with  ulcerating 
surface,  and  irregular  edges,  but  no  swelling  of  the  neighbouring  glands. 
A  diagnosis  was  made  of  the  chancre,  and  the  tumour  was  removed  by  the 
knife.  It  returned  in  the  scar,  and  was  again  removed,  but  the  eye  was 
injured.  Traumatic  choroiditis  ensued,  caused  sympathetic  irritation  in 
the  other  eye,  and  the  eye  was  consequently  enucleated.  There  were 
never  any  constitutional  symptoms  of  disease,  and  the  diagnosis  is  therefore 
extremely  doubtful. 

Galezowski  {Journal  d'  Ophthalmologies  1872)  reports  a  case  of  primary 


1878.] 


Bull,  Syphilis  of  the  Conjunctiva. 


407 


chancre  of  the  palpebral  conjunctiva.  In  the  upper  lid,  near  the  internal 
canthus,  could  be  seen  a  swelling  as  large  as  a  hazelnut,  which  could  be 
felt  through  the  skin.  The  lid  could  not  be  everted ;  but  by  drawing  it 
forcibly  away  from  the  eyeball  there  was  seen  an  ulcerating  surface  which 
reached  to  the  cul-de-sac,  and  suppurated  slightly.  The  sore  healed  by 
mercurial  treatment,  but  left  behind  an  extensive  symblepharon.  It  is  not 
stated  whether  the  patient  had  previously  manifested  any  symptoms  of 
constitutional  syphilis,  nor  whether  any  appeared  at  a  later  period,  and  it 
is  therefore  not  certain  that  this  was  the  initial  lesion.  The  symptoms 
would  answer  for  a  disintegrated  gummy  infiltration,  or  for  an  ulcerating 
tubercular  syphilide. 

Sturgis  reports  still  another  case  of  conjunctival  chancre  in  the  American 
Journal  o  f  Medical  Sciences,  January,  1873,  occurring  in  a  child,  set.  22 
months.  The  lower  lid  was  swollen  and  inflamed,  and  on  everting  it  there 
was  seen  near  the  outer  canthus  a  dusky-red  papule,  which  speedily 
changed  into  an  ulcer,  with  clean,  red  granulating  surface.  It  was  not 
indurated  at  first,  and  the  neighbouring  glands  were  not  examined.  One 
month  later  the  child  had  a  febrile  attack,  during  which  an  eruption  ap- 
peared upon  his  abdomen  and  chest.  Sturgis  first  saw  the  child  two 
months  after  the  appearance  of  the  lid-swelling,  and  then  the  induration 
was  marked.  The  ulcer  was  still  granulating,  and  there  was  a  general 
roseola  in  the  stage  of  decline,  and  mucous  patches  in  the  mouth.  The 
mode  of  origin  in  this  case  was  never  discovered. 

Bumstead  reports  a  case  of  initial  lesion  occurring  on  the  internal  sur- 
face of  the  uppei  lid.  {Treatise  on  Venereal  Diseases,  3d  edit.) 

Dietlen  mentions  a  case  of  chancre  of  the  conjunctiva  occurring  in  the 
left  eye  of  a  physician  three  or  four  weeks  after  he  had  examined  a  woman 
aifected  with  syphilitic  condylomata.  At  the  end  of  six  weeks  there 
appeared  a  general  roseola  and  infiltration  of  the  parotid  and  submaxillary 
glands.  The  lesion  was  situated  in  the  cul-de-sac,  where  there  was  marked 
induration,  and  the  ulcer  slowly  healed,  leaving  a  sclerosed  cicatrix. 
{Time  oV Erlangen,  1876.    Revue  des  Sciences  Medicales,  April  15,  1878.) 

Galezowski  further  refers  to  five  cases  of  indurated  chancre,  existing  on 
the  palpebral  edge  of  the  lid,  all  inoculated  upon  the  mucous  membrane, 
the  skin  not  being  involved  until  later.  He  does  not  regard  the  engorge- 
ment of  the  preauricular  and  submaxillary  glands  as  pathognomonic  of 
syphilis.  On  the  other  hand  almost  all  authorities,  and  especially  Lance- 
reaux.  estimate  the  importance  of  this  sign  as  great. 

The  writer  of  this  paper  has  during  the  past  year  had  an  opportunity  of 
seeing  and  treating  a  chancre  of  the  conjunctiva  which  tended  to  extend 
in  an  unusual  direction. 

The  patient  was  a  young  man,  ret.  29,  who  had  never  had  any  symptom 
of  venereal  disease  according  to  his  own  statement,  and  who  showed  no 
physical  signs  of  any  preceding  lesion  upon  his  body.    There  was  no 


408 


Bull,  Syphilis  of  the  Conjunctiva. 


[Oct. 


history  of  any  contamination,  so  that  the  mode  of  origin  of  the  ulcer  is 
unknown.  The  lower  lid  became  somewhat  inflamed,  swollen,  and  painful 
about  a  week  before  I  saw  him,  and  there  was  some  little  muco-purulent 
discharge,  which  collected  along  the  edges  of  the  lids  and  on  the  cilia.  On 
everting  the  lid,  deep  in  the  cul-de-sac,  about  a  quarter  of  an  inch  from  the 
external  canthus,  was  an  ulcerated  surface,  covered  by  a  grayish,  pulta- 
ceous  matter,  with  hard  base,  the  induration  extending  for  some  distance 
on  every  side.  The  ulcer  was  irregularly  oval,  about  half  an  inch  in  its 
longest  diameter,  and  extended  upwards  into  the  ocular  conjunctiva,  which 
was  very  much  thickened.  The  whole  conjunctiva,  both  ocular  and  pal- 
pebral, was  intensely  congested,  giving  the  appearance  of  an  aggravated 
conjunctivitis.  The  preauricular  gland  of  the  corresponding  side  was 
enlarged  and  tender,  and  later  the  same  symptoms  appeared  in  the  parotid 
and  submaxillary  glands.  A  diagnosis  of  chancre  was  made,  the  ulcer  was 
cauterized,  and  the  patient  placed  immediately  upon  anti-syphilitic  treat- 
ment. The  sore  pursued  the  usual  course,  healed  in  about  three  weeks, 
and  the  engorgement  of  the  glands  gradually  subsided.  About  nine  weeks 
after  the  occurrence  of  the  ulcer  there  appeared  a  roseola  upon  the  face  and 
hands,  which  soon  became  general.  Some  weeks  later  the  patient  com- 
plained of  his  mouth,  and  on  examination  showed  several  mucous  patches 
on  the  buccal  mucous  membrane,  and  one  on  the  side  of  the  tongue.  Any 
lingering  doubt  as  to  the  ulcer  having  been  the  initial  lesion  was  now  set 
at  rest.  The  patient  subsequently  suffered  from  an  attack  of  monocular 
iritis. 

There  seems  to  be  very  little  doubt  that  either  the  ciliary  margin  of  the 
lids  or  the  cul-de-sac  is  the  part  most  frequently  the  seat  of  the  conjunc- 
tival chancre.  There  are  some  rare  cases  reported  where  the  lesion  was 
in  the  ocular  conjunctiva  at  the  edge  of  the  cornea,  but  the  references  to 
these  cases  which  I  have  been  able  to  consult  were  so  slight  that  the 
diagnosis  needs  confirmation.  They  may  have  been  ulcerated  gummy 
deposits,  or  even  non-specific  ulcers. 

The  secondary  lesions  of  the  conjunctiva,  those  occurring  during  the 
period  of  constitutional  infection,  are  much  more  frequent  than  the  initial 
lesion.  Lancereaux  describes  them  as  small  circumscribed  spots,  elevated, 
non-vascular,  and  of  a  reddish-gray  or  coppery  colour,  not  differing  much 
from  certain  eruptions  on  the  skin  with  which  they  may  coexist.  Gale- 
zowski  affirms  broadly  that  syphilitic  affections  of  the  conjunctiva  are 
either  chancres  or  mucous  patches.  Again,  Desmarres  says  that  he  has 
never  seen  any  mucous  patches  or  coppery  eruptions  on  the  conjunctiva. 
But  the  mucous  patch  is  certainly  not  the  only  lesion  found  at  this  period 
in  the  conjunctiva,  for  papules  and  pustules  are  not  rarely  seen  here, 
accompanying  other  signs  of  constitutional  syphilis.  Thus,  Lawrence 
(A  Treatise  on  the  Venereal  Diseases  of  the  Eye,  London,  1830)  reports 
a  case  of  syphilitic  iritis  with  a  general  papular  eruption,  in  which  there 
were  a  few  pustules  on  the  mucous  membrane  of  the  lids,  appearing  as 
small  yellow  points  the  size  of  a  large  pin's  head.  In  another  case  of 
general  papular  eruption,  there  were  found  several  yellow  pustules  in  the 
palpebral  conjunctiva,  which  caused  a  great  deal  of  "  uneasiness  and 


1878.] 


Bull,  Syphilis  of  the  Conjunctiva. 


409 


swelling  of  the  lids."  In  still  another  case,  where  the  eruption  was  tuber- 
cular, chiefly  affecting  the  face  and  tibias,  the  upper  lid  of  one  eye  became 
swollen  ;  and  on  everting  it,  an  eruption  of  small  pustules  was  observed 
upon  the  conjunctival  surface.  In  a  fourth  case,  with  ulcers  in  several 
parts  of  the  body,  and  periosteal  nodes,  Lawrence  observed  that  the  left 
upper  lid  was  red  and  swollen,  and  on  everting  it  he  discovered  on  the 
inner  surface  a  sore  as  large  as  a  sixpence,  with  a  tawny  surface  which  did 
not  extend  as  far  as  the  ciliary  margin  of  the  lid. 

These  sores  with  tawny  surfaces  are  not  very  uncommon,  and  are  prob- 
ably ulcerated  mucous  patches.  I  have  seen  several  within  a  compara- 
tively recent  period,  and  will  cite  one  case  in  detail  as  showing  how  a 
mucous  patch  or  condyloma  on  the  conjunctiva  grows. 

The  patient  was  a  young  man,  aet.  22,  whom  I  saw  for  the  first  time  on 
October  11th,  1877.  The  chancre  had  been  contracted  about  four  months 
previously,  and  he  had  sore  throat  and  a  general  eruption,  probably  a 
roseola,  before  I  saw  him.  At  the  above-mentioned  date,  he  presented 
himself  with  an  iritis  of  the  left  eye  and  a  general  papular  eruption.  Two 
days  later,  he  noticed  that  the  upper,  lid  of  the  left  eye  was  somewhat 
swollen  and  tender  to  the  touch.  On  everting  it,  there  was  seen  an  ele- 
vation of  the  conjunctiva  over  the  centre  of  the  lid,  something  like  a 
small  vesicle,  as  if  there  had  been  an  effusion  beneath  it,  and  a  localized 
engorgement  of  the  vessels.  The  next  day,  this  elevation  had  extended 
and  was  more  resistant  to  the  touch,  as  if  the  effusion  were  not  fluid.  The 
vascular  injection  was  also  more  marked.  The  extension  continued 
steadily  until,  on  the  sixth  day,  the  signs  of  a  mucous  patch  were  unmis- 
takable. It  was  oval  in  shape,  somewhat  more  than  half  an  inch  long,  its 
long  diameter  corresponding  with  the  long  diameter  of  the  lid,  and  it  did 
not  reach  the  ciliary  margin  of  the  lid.  It  had  the  reddish-gray  colour  and 
moist  surface  which  we  are  all  accustomed  to  see.  This  surface  subse- 
quently ulcerated,  became  very  red  and  painful ;  the  ulcer  extended  super- 
ficially, and  had  an  offensive  discharge.  It  eventually  healed,  though  for 
a  time  it  resisted  treatment  obstinately,  and  the  resulting  cicatrix  produced 
a  slight  entropium  of  the  inner  lip  of  the  ciliary  margin  of  the  lid. 

It  is  a  well-recognized  fact  that  mucous  patches  ulcerate  easily,  and  it 

is  not  improbable  that  some  of  the  reported  cases  of  soft  chancre  of  the 

conjunctiva  are  ulcerated  mucous  patches.    There  is  such  a  case  published 

in  the  Gazette  des  Hopitaux,  No.  11,  Jan.  27th,  1866. 

A  woman,  set.  22,  had  mucous  patches  on  the  vulva  and  labia  majora.  The 
lower  lid  was  red  and  painful  at  the  external  canthus,  and  the  ocular  conjunctiva 
was  injected.  There  was  no  lachrymation  and  no  secretion  cf  any  kind.  The 
ocular  conjunctiva  became  chemotic,  and  the  eye  could  not  be  opened,  owing  to 
the  increased  swelling  of  the  lids.  Four  days  later,  the  swelling  had  subsided 
somewhat,  and  on  everting  the  upper  lid  there  was  seen  near  the  canthus  an  ele- 
vation of  the  mucous  membrane  of  a  deep  red  colour,  the  size  of  a  small  pea, 
with  ulcerated  surface.  The  cornea  was  healthy,  but  the  ocular  conjunctiva  was 
deep  red  and  lay  in  folds  as  far  as  the  cul-de-sac.  The  case  was  well  advanced 
towards  recovery  on  the  fourth  day  after  the  treatment  began,  and  its  site  later 
could  only  be  recognized  by  the  deep  red  tinge  of  the  conjunctiva,  which 
remained. 

Though  ulcerations  of  the  conjunctiva  usually  occur  with  other  syphilitic 


410 


Bull,  Syphilis  of  the  Conjunctiva. 


[Oct. 


ulcers  on  different  parts  of  the  body,  yet,  as  before  observed,  they  result 
from  the  disintegration  of  gummy  infiltration  as  a  rule,  and  not  from 
mucous  patches.  Yet,  gummy  tumours  do  not  always  precede  syphilitic 
ulceration.  In  isolated  cases,  the  process  begins  with  infiltration  of  a  por- 
tion of  the  conjunctiva,  but  quickly  ulcerates  and  forms  a  conjunctival 
ulcer,  which,  according  to  Stellwag,  is  easily  distinguished  from  the  sur- 
rounding tissue  by  its  fatty -looking  coating,  irregularly  eroded  edges,  and 
uneven  base.  If  properly  treated,  these  ulcers  generally  cicatrize  rapidly. 
According  to  Hirschler,  if  the  ulcer  was  on  or  near  the  ciliary  edge  of  the 
lid,  the  cicatrix  itself  is  very  characteristic.  It  appears  as  a  tendinous 
white  cord,  entirely  devoid  of  cilia,  sharply  defined,  which  extends  through 
the  entire  thickness  of  the  edge  of  the  lid,  and  forms  an  excavation  in  con- 
sequence of  its  great  shrinkage. 

In  the  British  Medical  Journal  for  March  18th,  1865,  there  is  a  report 
of  the  proceedings  of  the  Medical  Section  of  the  Manchester  Royal  Insti- 
tution for  February  1st  of  the  same  year,  in  which  an  account  is  given  of 
a  syphilitic  ulceration  of  the  palpebral  conjunctiva,  which  is  of  somewhat 
doubtful  origin.  The  margins  of  the  lids  were  red  and  swollen,  and  on 
everting  the  upper  lids,  two  small  ulcers  were  seen  on  one,  and  one  on  the 
other.  Each  Mas  slightly  excavated,  with  yellowish  base,  and  about  the 
size  of  a  split  pea.  They  were  all  three  in  the  palpebral  conjunctiva, 
quite  within  the  ciliary  margin  and  not  observable  till  the  lids  were 
entirely  everted.  In  one  of  the  patients  there  was  a  yellowish  ulcer  on 
the  left  tonsil,  and  some  serpiginous  ulcers  on  the  legs.  Mr.  Windsor, 
who  reported  the  cases,  regarded  them  as  comparatively  rare,  and  stated 
that  they  occurred  in  cases  of  the  phagedenic  form  of  ulceration.  As  the 
ulceration  in  these  cases  involved  the  tarsal  cartilage,  they  probably 
belonged  to  the  class  of  disintegrated  gummata. 

There  is  another  point  of  interest  in  these  superficial  ulcers  on  the  con- 
junctiva, and  that  is  their  isolated  occurrence  as  a  symptom  of  consti- 
tutional syphilis.  The  patient  may  have  been  free  from  all  symptoms  of 
disease  for  several  years,  wiien  suddenly  the  conjunctival  lesion  makes  its 
appearance,  runs  its  course,  is  healed,  and  again  the  patient  is  free  from 
all  symptoms.  Thus,  Lawrence  cites  the  case  of  a  gentleman  who  had  a 
large  ulcer,  with  dirty  whitish  surface,  on  the  conjunctiva  of  the  upper  lid 
of  one  eye,  and  who  had  had  no  other  symptoms  of  syphilis  for  three  or 
four  years.  The  writer  has  himself  seen  a  case  of  large  superficial  ulcer 
of  the  palpebral  conjunctiva  in  a  man  who  had  had  no  sign  of  disease 
for  more  than  two  years.  The  sore  healed  under  mercurial  treatment, 
and  no  other  lesion  made  its  appearance  during  the  observation  of  the 
case. 

A  third  variety  of  conjunctival  lesion  in  constitutional  syphilis  is  the 
gummy  infiltration,  circumscribed  and  diffuse  ;  and  this  is  probably  the 
least  common  of  all.    Gumma  of  the  sclera,  involving  sometimes  the 


1878.] 


Bull,  Syphilis  of  the  Conjunctiva. 


411 


fibrous  capsule  of  the  eyeball,  is  not  an  uncommon  late  symptom  of  syphi- 
lis, but  gumma  of  the  conjunctiva  is  certainly  rare.  Late  manifestations 
of  syphilis,  occurring  in  the  tertiary  period,  are  rarely  limited  to  the  con- 
junctiva, but  usually  beginning  in  other  tissues,  involve  the  mucous  mem- 
brane by  contiguity  of  structure.  Under  this  head  must  probably  be 
classed  the  case  described  by  Tavignot  (Bulletin  de  Therapeutique,  Octo- 
ber, 1846),  and  referred  to  in  Schmidt's  Jahrbucli,  Band  lv.,  p.  217. 

The  patient  was  a  man,  set.  44,  who  Lad  had  no  sign  of  syphilis  for  twenty  years. 
He  presented  himself  witli  a  tumour  of  the  size  of  a  bean  upon  the  right  upper  lid. 
This  was  removed,  but  fifteen  months  later  there  appeared  a  number  of  small 
growths  upon  the  palpebral  eonjunetiva  of  the  same  eye.  In  addition  there  were 
three  small  new  tumours ;  the  largest  was  on  the  left  upper  lid,  appeared  united 
with  the  cartilage,  and  was  covered  by  a  reddish,  ulcerated  skin ;  a  second,  about 
the  same  size,  and  more  movable,  was  on  the  right  upper  lid;  the  skin  over  it 
was  reddened,  and,  when  the  lid  was  everted,  there  was  seen  a  small  fistula  at 
the  site  of  the  tumour,  through  which  a  fine  probe  could  be  passed  for  a  distance 
of  several  millimetres.  The  third  tumour  was  very  small,  and  appeared  at  the 
external  angle  of  the  right  upper  lid.  There  were  small  ulcers  at  various  spots  in 
the  conjunctiva,  particularly  near  the  ciliary  margin.  The  syphilitic  nature  of 
the  lesions  was  proved  by  a  clear  history  of  symptoms  and  the  presence  of  nu- 
merous coppery  blotches  upon  the  patient.  The  ulcers  and  tumours  of  the  lids 
healed  under  a  course  of  mercury. 

Lawrence  (loc.  cit.)  cites  an  interesting  case  of  inherited  syphilis,  in 
which  an  ulcer  appeared  on  the  palpebral  conjunctiva,  and  spread  super- 
ficially ;  but  the  case  is  not  reported  with  sufficient  care  to  enable  us  to 
decide  whether  the  lesion  was  primarily  an  ulcer  or  a  gummy  infiltration. 

The  child  was  a  boy,  a?t.  4,  who  was  born  healthy  of  a  syphilitic  mother,  and 
the  first  sign  of  any  trouble  appeared  when  he  was  three  years  and  four  months 
old.  Both  eyes  became  inflamed  with  great  pain  and  photophobia,  but  Lawrence 
does  not  say  whether  this  was  an  attack  of  iritis  or  of  something  else.  Two 
months  later  a  general  eruption  appeared  over  the  whole  body,  which  disap- 
peared under  treatment.  One  month  later  the  eruption  broke  out  again,  and  the 
eyes  became  sore.  An  examination  showed  reddened  and  swollen  upper  lids  in 
both  eyes,  and  on  everting  the  right  upper  lid,  the  mucous  membrane  was  found 
very  much  swollen,  and  a  large  ulcer,  with  elevated  margin  and  foul  surface, 
extended  the  whole  length  of  the  lid,  but  did  not  reach  the  ciliary  margin.  The 
conjunctiva  of  the  left  upper  lid  was  not  ulcerated.  The  results  of  treatment  are 
not  given. 

Magni  has  seen  in  syphilitic  patients,  after  an  iritis,  the  development  of 
small,  discrete  tumours  in  the  conjunctiva,  varying  in  size  from  a  pea  to 
a  bean,  semi-globular  in  shape,  with  white  summit  and  red  base.  Under 
the  microscope  they  were  found  to  consist  of  a  mass  of  young  cells  lying 
in  a  granular  matrix.  He  cites  a  case  of  what  he  calls  "  Keratoconjunc- 
tivitis Gummosa"  in  the  Giornale  d'  Oftalmologia,  1863,  which  is  quoted 
in  the  Annales  d'  Oculistique,  vol.  li.,  p.  113. 

The  patient  was  a  woman,  set.  44.  Nothing  very  accurate  was  known  of  her 
previous  history,  but  during  the  lactation  of  her  second  child,  syphilitic  ulcers 
appeared,  it  is  not  said  where ;  and  later  cutaneous  syphilides  and  iritis  of  the 
right  eye.  In  January,  1863,  when  Magni  saw  her,  the  lids  were  oedematous; 
there  was  photophobia,  lachrymation,  and  violent  pain  in  both  eyes.  The  palpe- 
bral conjunctiva  was  only  slightly  injected,  but  on  the  ocular  conjunctiva  there 
were  seen  semi-globular  tumours,  varying  in  size  up  to  a  large  pea.  With  the 
exception  of  those  situated  close  to  the  corneal  margin,  they  were  freely  movable 


412 


Bull,  Syphilis  of  the  Conjunctiva. 


[Oct. 


with  the  conjunctiva.  Other  tumours  soon  formed,  and  the  first  grew  larger. 
On  the  external  margin  of  the  cornea  there  were  three  small  nodules,  and  the 
corneal  epithelium  was  cloudy  in  the  vicinity.  The  aqueous  was  turbid,  there 
were  posterior  synechias,  and  vision  was  reduced  to  recognizing  large  objects. 
Some  of  these  nodules  were  excised  and  examined  microscopically,  and  showed 
the  usual  appearances  of  gummy  infiltration.  Under  mercurial  treatment  all  the 
nodules  disappeared  without  ulceration. 

Hirschberg  speaks  of  what  he  calls  "  conjunctivitis  gummosa,"  and  de- 
scribes three  cases.  They  began  as  small  growths,  the  size  of  a  pea, 
which  rapidly  ulcerated.  They  had  an  infiltrated  yellow  base  and  eroded 
margins,  and  were  accompanied  by  slight  diffuse  swelling  of  the  conjunc- 
tiva. My  knowledge  of  these  cases  is  simply  from  reference,  as  I  have 
not  been  able  either  to  consult  the  original,  or  to  find  out  exactly  where 
they  are  published.  The  matter  is  also  referred  to  in  A.  von  Graefe's 
KUnische  Vortraege,  i. 

The  rare  form  of  syphilitic  conjunctival  disease,  called  by  Smee  "con- 
junctival blotch,"  was  probably  of  the  same  gummy  nature. 

Smee's  case,  reported  in  the  London  3fcdical  Gazette  for  December  13.  1844, 
was  a  woman  who  had  at  first  a  small  ulcer  on  the  edge  of  the  eyelid.  She  and 
her  husband  had  suffered  from  syphilis  for  several  years.  There  were  numerous 
copper-coloured  spots  on  various  parts  of  the  body,  and  later  there  appeared  in 
the  ocular  conjunctiva,  just  below  the  cornea,  a  spot  as  large  as  a  silver  penny, 
raised  above  the  surrounding  surface,  its  colour  coppery,  but  not  opaque,  and  with 
no  abnormal  vascularity.  The  surrounding  conjunctiva  was  oedematous.  Smee 
regarded  this  eruption  as  analogous  to  purpura,  and  as  distinct  from  the  pustules 
of  the  conjunctiva  sometimes  found  associated  with  a  pustular  syphilide.  The 
eruption  disappeared  under  the  use  of  potass,  iodide. 

In  Guy's  Hospital  Reports  for  1861,  p.  100,  Mr.  France  speaks  of 
"syphilitic  blotch  of  the  conjunctiva,"  and  reports  three  cases.  II<  de- 
scribes it  as  a  circumscribed  and  well-defined  discoloration  of  the  ocular 
conjunctiva  around  the  corneal  margin,  which,  within  the  affected  area, 
is  slightly  thickened  and  raised,  but  not  more  vascular  than  the  neighbour- 
ing surface.  There  is  no  disposition  to  ulceration,  as  when  the  margin  of 
the  lid  is  attacked  by  syphilis.  The  duration  of  the  blotch,  if  not  treated, 
is  very  protracted. 

France's  first  case  was  a  woman  in  whom  the  blotch  occupied  the  entire  lower 
half  of  the  ocular  conjunctiva  of  the  right  eye.  His  second  case  was  a  man,  with 
a  tubercular  syphilide  on  the  face,  at  the  angles  of  the  nose,  and  on  the  upper  lip. 
On  the  conjunctiva  of  the  right  eye  were  three  blotches,  a  large  one  at  the  nasal 
side  of  the  cornea,  and  two  smaller  ones  at  the  temporal  side.  The  third  case 
was  in  a  boy,  set.  3,  with  inherited  syphilis.  Three  weeks  after  birth  the  child 
was  covered  by  an  eruption,  which  disappeared  after  a  month's  treatment.  Soon 
after  a  sanguineo-purulent  discharge  began  in  both  eyes.  He  recovered  from 
this  in  about  two  months,  and  remained  well  till  eighteen  months  of  age,  when 
the  whole  body  was  again  covered  by  an  eruption,  and  then  both  eyes  became 
affected  by  a  partial  and  abruptly-defined  discoloration  and  thickening  of  the 
conjunctiva  around  the  corneas. 

Wecker's  case  of  gummy  tumour  of  the  conjunctiva  (Traite  des  Mala- 
dies des  Yeux,  1867,  i.,  p.  177)  in  some  points  resembles  Smee's  case. 

His  patient  was  a  woman,  ast.  38,  in  whom  the  growth  was  in  the  conjunctiva 
of  the  left  eye,  between  the  margin  of  the  cornea  and  the  insertion  of  the  exter- 


1878.] 


Bull,  Syphilis  of  the  Conjunctiva. 


413 


nal  rectus  muscle.  The  surface  was  ulcerated,  and  the  tumour  very  painful. 
An  attempt  was  made  to  remove  it,  but  for  some  reason  failed,  and  the  pain  was 
increased.  When  Wecker  first  saw  the  case  he  thought  it  was  an  epithelioma,  but 
a  careful  examination  revealed  numerous  coppery  blotches  upon  the  face,  and  an 
ulcerated  tubercular  syphilide  upon  the  arm.  Sichel,  who  also  saw  the  case, 
called  it  certainly  epithelioma.  Under  an  antisyphilitic  treatment  the  pain  soon 
ceased,  the  tumour  began  to  grow  smaller,  and  at  the  end  of  two  months  the  cure 
was  complete,  leaving  only  a  slight  cicatricial  line  along  the  corneal  margin. 

In  the  KUnische  Monatsbl'dtter  fiir  Augenheilkunde,  Sept.  1870,  Prof. 
Estlander  reports  a  case  of  conjunctival  gumma  very  like  Wecker's  case. 

The  patient,  a  young  girl,  set.  19,  who  showed  signs  of  tertiary  syphilis,  pre- 
sented herself  at  the  general  hospital  for  treatment.  While  an  inmate,  with 
numerous  syphilitic  ulcers  on  various  parts  of  the  body,  there  developed  at  the 
external  margin  of  the  left  cornea  a  fiat  and  smooth  tumour  in  the  conjunctiva, 
with  a  horizontal  diameter  of  about  five  (5  mm.)  millimetres,  and  a  vertical 
diameter  of  three  (3  mm.)  millimetres.  In  the  centre  of  the  growth  the  conjunc- 
tiva was  gray,  with  beginning  ulceration.  This  tumour  disappeared  in  a  week 
under  mercurial  inunction,  leaving  a  deep  gray  scar.  Potass,  iodid.  proved  use- 
less in  the  treatment. 

Still  another  case  of  gummy  tumour  of  the  ocular  conjunctiva  is  re- 
ported by  Briere  in  the  Annates  d'  Oculistique,  1874,  tome  lxxii., 
p.  105. 

The  patient,  a  man,  set.  25,  had  had  the  initial  lesion  four  years  before.  Later 
came  a  papulo-tubercular  syphilide,  which  lasted  a  long  time.  Then  appeared 
exostoses  on  the  clavicles,  ribs,  ulna?,  and  tibia?,  with  osteo-periostitis,  so  that  for 
two  years  he  had  walked  with  crutches.  He  had  intense  cephalalgia,  facial 
palsy,  and  had  become  silly  from  some  lesion  of  the  brain  or  meninges.  There 
was  also  caries  of  the  turbinated  bones  and  vomer,  and  of  the  entire  alveolar  arch 
of  the  left  superior  maxilla.  In  August,  1874,  there  appeared  a  marked  injection 
of  the  ocular  conjunctiva  of  the  right  eye,  with  photophobia  and  lachrymation. 
The  cornea  and  iris  were  not  inflamed,  and  the  media  were  clear ;  but  on  lifting 
the  upper  lid,  and  making  the  patient  look  down,  there  was  seen  at  about  (6  mm.) 
six  millimetres  from  the  corneal  margin,  between  the  external  and  superior  rectus 
muscles,  a  tumour  in  the  conjunctiva  of  a  yellow  colour  and  firm  consistence, 
about  the  size  of  a  large  bean.  Under  antisyphilitic  treatment  this  conjunctival 
growth  diminished  slowly,  and  after  one  month  there  was  only  seen  a  slight  thick- 
ening of  the  conjunctiva  at  the  point  where  the  tumour  had  been. 

The  following  case  of  gummy  infiltration  of  the  conjunctiva,  with  gum- 
mata  of  the  sclera,  was  under  my  own  care,  and  as  the  case  is  of  consider- 
able interest  from  its  rarity,  the  history  will  be  given  in  detail.  The 
combination  of  constitutional  syphilis  with  a  certain  group  of  symptoms 
that  somewhat  resembled  scurvy,  the  general  marasmus  which  subse- 
quently set  in,  and  finally  the  death  from  pneumonia,  made  a  complicated 
case  that  was  interesting  to  follow. 

Louis  B.,  ast  56,  native  of  Canada,  and  by  occupation  a  labourer,  was 
admitted  to  Charity  Hospital,  Blackwell's  Island,  August  11,  1877.  The 
patient  is  a  tall,  robust  man,  but  prematurely  aged  in  appearance. 

Previous  History  Had  always  been  a  healthy  man  until  the  autumn 

of  1876,  when  he  caught  a  severe  cold,  and  was  admitted  to  the  hospital 
for  simple  bronchitis.  At  the  end  of  ten  days  he  was  discharged  cured, 
not  having  been  confined  to  his  bed  for  a  single  day.  Remained  well  till 
the  following  summer,  when  he  again  caught  cold  and  was  readmitted  to 
the  hospital  on  August  11th.    He  had  a  dry  cough,  pain  in  the  chest  on 


414 


Bull,  Syphilis  of  the  Conjunctiva. 


[Oct. 


both  sides  running  through  to  the  back,  an  elevated  temperature  and 
accelerated  pulse,  with  all  the  physical  signs  denoting  acute  pleurisy,  with 
slight  effusion  on  both  sides. 

Fifteen  years  ago  he  had  had  two  attacks  of  gonorrhoea,  with  an  interval 
of  about  six  months  between  them.  He  positively  denied  ever  having 
suffered  from  any  symptom  of  syphilitic  disease. 

He  was  admitted  to  the  ophthalmic  ward  of  the  hospital  on  August  16, 
1877.  He  stated  that  two  or  three  days  before  he  had  felt  a  sensation 
of  soreness  in  the  left  eye,  and  on  the  following  day  in  the  right  eye. 
The  pain  became  dull,  burning,  and  continuous,  was  located  in  the  eye- 
balls, and  was  accompanied  by  lachrymation.  Whenever  he  swallowed, 
whether  fluids  or  solids,  he  felt  a  very  severe  pain  in  the  eyes,  and  this 
was  immediately  followed  by  marked  blepharospasm. 

Nothing  particular  about  the  man's  general  appearance,  except  a  pale, 
dull-yellow  complexion  and  a  look  of  hopeless  wretchedness.  An  exami- 
nation of  the  abdomen  and  back  revealed  the  marks  of  an  extensive  old 
eruption,  consisting  of  small  white  cicatrices  with  deep  brown  pigmented 
margins,  irregularly  arranged.  These  have  been  there  for  twenty  years. 
Upon  the  hands  and  face  there  was  a  peculiar  eruption,  composed  of  ele- 
vated spots  with  flat  tops,  some  round,  others  oval,  yellowish-red  in  colour, 
with  a  narrow  dark-red  areola  ;  neither  painful  nor  tender  to  the  touch, 
and  presenting  a  mid-state  between  vesiculation  and  pustulation.  On 
opening  these,  a  thin,  watery  pus  mixed  with  blood  could  be  pressed  out. 
These  vesicles  or  pustules  were  scarcely  large  enough  to  be  called  bullae, 
and  yet  there  was  conveyed  to  the  mind  a  general  idea  of  pemphigus. 
One  of  the  largest  pustules  was  on  the  left  upper  lid,  and  there  were  two 
smaller  ones  along  its  ciliary  margin.  There  were  several  on  the  face, 
and  the  remains  of  a  large  one  on  the  bridge  and  right  side  of  the  nose. 
On  the  hands  the  eruption  was  almost  entirely  on  the  dorsal  surface,  and 
was  grouped  around  the  knuckles  and  between  the  fingers.  Some  vesicles 
on  being  opened  gave  exit  only  to  blood. 

The  eyes  were  almost  identical  in  appearance.  Surrounding  the  corneas 
there  was  a  growth,  most  marked  on  the  outer  and  lower  sides,  varying  in 
height  from  one  and  a  half  to  two  lines,  seated  in  and  beneath  the  ocular 
conjunctiva.  This  growth  extended  away  from  the  cornea  on  all  sides 
about  one-third  of  an  inch,  was  pale  yellow  in  colour,  moderately  hard  to 
the  touch,  with  an  irregular,  knobby  surface  and  apparently  destitute  of 
vessels.  The  conjunctiva  was  firmly  adherent  to  this  growth,  and  the 
cornea  was  imbedded  in  this  Avail  like  a  watch-crystal  in  its  frame.  On 
being  incised,  it  cut  like  brawn  and  the  hemorrhage  was  very  slight. 
Upon  the  sclera  of  each  eye,  between  the  tendons  of  the  superior  rectus 
and  external  rectus  muscles,  and  partially  covering  the  latter,  was  an 
extensive  and  extremely  well-marked  gummy  infiltration  of  the  sclera, 
very  vascular,  very  tender  to  the  touch,  and  especially  painful  when  the 
eyes  were  turned  outwards.  This  infiltration  extended  backwards  sym- 
metrically in  the  two  eyes,  but  was  somewhat  more  extensive  in  the  right 
eye.  The  media  were  clear,  and  an  ophthalmoscopic  examination  revealed 
nothing  abnormal  in  the  deeper  tunics  of  the  eyes.  The  patient's  breath 
was  fetid,  the  buccal  mucous  membrane  very  pale,  and  bore  the  marks  of 
the  teeth  along  the  cheek.  Tongue  moist  and  thinly  coated,  appetite  poor, 
bowels  obstinately  constipated.  Temperature  100^,  pulse  102,  intellect 
dull,  answered  questions  very  slowly.  Physical  signs  of  pneumonia  well 
marked  over  both  lungs. 


1878.] 


Bull,  Syphilis  of  the  Conjunctiva. 


415 


A  diagnosis  was  made  of  syphilitic  pemphigus,  gummy  tumour  of  the 
sclera  of  both  eyes,  and  pericorneal  gummy  infiltration  of  the  conjunctiva, 
and  double  pleuro-pneumonia.  The  patient's  condition  was  very  bad,  and 
a  vigorous  tonic  and  restorative  treatment,  combined  with  mercurial  inunc- 
tion and  potass,  iodide,  was  at  once  instituted.  Quinia,  dilute  sulphuric 
acid,  and  iron  were  regularly  administered.  Potass,  iodid.  grs.  xx  ter 
die,  and  the  inunction  night  and  morning,  and  a  liberal  diet  of  milk,  eggs, 
beef-tea,  and  eight  ounces  of  whiskey  daily. 

The  patient  grew  slowly  worse,  with  occasional  delirium,  and  in  the  in- 
tervals of  delirium  the  stupor  steadily  deepening.  Potass,  iodidi  grs.  xxx 
three  times  daily.    Diminution  of  conjunctival  infiltration. 

August  26.  Integument  dusky,  breath  very  fetid,  gums  spongy  and  bleed- 
ing. Urine  is  turbid,  sp.  gr.  1015,  contains  a  trace  of  albumen,  some  pus 
corpuscles,  and  a  large  number  of  triple  phosphate  crystals.  Spots  on  the 
hands  are  growing  larger,  and  approaching  bullae  in  appearance.  Skin 
very  dry  and  hot.  A  swelling  has  made  its  appearance  over  the  inner 
condyle  of  the  right  arm,  painful  on  pressure.  This  swelling  soon  ex- 
tended down  the  right  forearm,  pitted  on  pressure,  and  was  doughy  to  the 
touch ;  the  right  hand  acdematous,  also  both  legs  and  feet. 

27th.  Painful  diarrhoea,  attended  by  tenesmus,  rumbling  and  bloody 
discharges;  face  puffy,  repeated  bleeding  from  the  gums  and  nose.  Pa- 
tient is  semi-comatose.  Consolidation  detected  at  apices  of  both  lungs, 
with  some  friction  sounds  on  the  left  side.  The  scleral  growths  and  the 
pericorneal  conjunctival  groivths  have  almost  entirely  disappeared.  The 
spots  on  the  hands  and  face  are  increasing  in  size,  and  becoming  more  red 
in  colour. 

'29th.  Diarrhoea  ceased;  mercury  discontinued;  transferred  to  pavilion 
on  account  of  delirium.  Right  cheek  swollen,  especially  near  angle  of 
mouth,  and  spots  of  ulceration  on  buccal  surface  opposite  first  molar  tooth 
in  upper  jaw  ;  right  forearm  swollen,  red,  hot,  and  tense. 

31st.  Right  cheek  swollen  enormously;  eruption  decidedly  hemorrhagic. 

Sept.  3.  Incisions  in  right  forearm  necessary  to  relieve  tension ;  consid- 
erable pus  discharged  through  the  incisions;  patient  much  relieved.  Swell- 
ing of  right  cheek  still  more  marked,  and  at  one  point  on  mucous  surface 
a  somewhat  extensive  black  slough.    Eyes  entirely  well. 

6th.  Constant  delirium ;  slough  in  cheek  extending ;  eruption  drying  up ; 
arm  doing  very  well ;  scarcely  any  febrile  action. 

16th.  Large  hole  sloughed  through  the  entire  thickness  of  the  cheek; 
delirium  has  turned  to  coma;  steady  improvement  in  the  arm. 

19th.  Death  at  4  P.  M.  in  deep  coma. 

Autopsy,  20jj  hours  after  death  Body  emaciated ;  on  back  of  hands 

a  number  of  bluish-red  spots,  varying  in  size  from  a  three-cent  piece  to  a 
dime.  Beneath  the  right  malar  bone  a  round,  clean-cut  ulceration  of  all 
the  tissues  of  the  cheek,  which  extends  to  the  angle  of  the  mouth,  but  does 
not  involve  it.  All  the  tissues  involved  in  the  ulceration  form  a  soft,  pulpy, 
brownish-red,  offensive  mass.  Right  half  of  tongue  destroyed  by  ulcera- 
tion; right  half  of  inferior  maxilla,  from  symphysis  to  angle,  is  denuded  of 
periosteum  and  base,  and  same  condition  exists  in  the  right  superior 
maxilla. 

Calvarium  unusually  thin;  dura  mater  normal;  increased  amount  of 
cerebro-spinal  fluid ;  pia  mater  oedematous ;  sinuses  empty ;  vessels  at  base 
of  brain  normal.  At  posterior  portion  of  right  hemisphere  is  a  spot  of 
softening  about  an  inch  in  diameter,  breaking  down  immediately  on 
section. 


416 


Bull,  Syphilis  of  the  Conjunctiva. 


[Oct. 


TJioracic  cavity  contains  about  ten  ounces  of  clear  serous  effusion ;  on 
right  side  a  few  bands  of  adhesion  at  apex  ;  on  left  side  a  few  bands  of  ad- 
hesion at  base  to  diaphragm ;  upper  lobe,  central  portion  of  middle  lobe, 
and  greater  portion  of  lower  lobe  of  right  lung  in  stage  of  gray  hepatiza- 
tion, associated  with  emphysema.  In  left  lung  entire  lower  lobe  the  seat 
of  catarrhal  pneumonia  passing  into  gray  stage ;  upper  lobe  emphysematous 
and  (Edematous. 

Heart. — Both  ventricles  hypertrophied  and  dilated;  on  leaflets  of  aortic 
valves  are  soft  vegetations ;  in  pericardial  cavity  about  half  an  ounce  of 
clear  serous  effusion. 

Abdomen  Liver  fatty;  capsule  of  spleen  thickened,  and  its  parenchy- 
ma almost  diffluent ;  in  cortex  of  kidneys  several  small  abscesses,  size  of  a 
split  pea ;  in  both  pyramidal  and  cortical  portions  are  evidences  of  chronic 
interstitial  nephritis.    Pelves  and  ureters  contain  a  small  amount  of  pus. 

Intestines  are  normal,  except  a  few  chronic  ulcerations  in  the  caecum. 

Situated  in  the  median  line  of  the  neck,  below  and  between  the  lateral 
lobes  of  the  thyroid  gland,  is  a  tumour  the  size  of  an  English  walnut,  just 
beneath  the  subcutaneous  fascia ;  it  is  soft  and  fluctuating,  and  on  section 
was  found  filled  with  disintegrated  coagukw  On  the  internal  surface  of  its 
walls  were  a  few  calcareous  plates.    Pharynx  and  trachea  normal. 

The  points  of  interest  in  the  case  are  as  follows : — 
1st.  The  rarity  of  the  pericorneal,  conjunctival  growth. 
2d.  Its  coincidence  with  and  yet  independence  of  the  gummy  infiltration 
of  the  sclera. 

3d.  The  cyst  in  the  neck,  with  its  disintegrated  contents,  unrecognized 
before  death. 

4th.  The  vesiculo-pustular  eruption  becoming  pemphigoid  and  subse- 
quently hemorrhagic. 

5th.  The  hemorrhagic  diathesis  as  shown  in  the  various  symptoms. 

Of  course,  gummy  infiltration  of  the  sclera  and  episcleral  tissue  is  a  com- 
mon enough  manifestation  of  constitutional  syphilis,  and  the  scleral  gum- 
mata  in  this  case  occupied  the  usual  site ;  that  is,  in  the  neighbourhood  of 
the  external  rectus  muscle.  Though  the  infiltration  was  extensive,  this  is 
not  uncommon,  and  it  extended  in  the  usual  direction  from  before  back- 
wards, towards  and  beyond  the  equator  of  the  eyeball.  Furthermore  it 
was  binocular  and  symmetrical,  as  is  usually  the  case  in  syphilitic  lesions 
of  the  eye.  As  regards  the  conjunctival  gummata  in  this  case,  no  ulcera- 
tion occurred.  Their  appearance  at  first,  and  their  mode  of  growth,  resem- 
bled very  much  the  description  given  by  Smee  of  his  case.  They  began 
as  a  dirty  discoloration  in  small  patches  in  the  conjunctiva  around  the 
cornea,  with  at  first  scarcely  any  elevation.  These  patches  then  coalesced, 
gained  in  thickness  and  breadth,  and  thus  formed  the  wall  round  the  cor- 
nea. They  then  remained  unchanged  until  the  system  came  under  the 
influence  of  the  mercury,  and  then,  in  spite  of  the  patient's  generally  de- 
praved physical  condition,  they  rapidly  subsided  and  disappeared  before 
the  scleral  infiltration  was  absorbed. 

The  conjunctiva  and  sclera  were  normal  in  appearance  between  this 


1878.] 


Bull,  Syphilis  of  the  Conjunctiva. 


417 


circum-corneal  wall  and  the  gummy  tumour  of  the  sclera  near  the  external 
rectus  muscle.  There  was  no  increased  vascularity  of  the  eyeball,  except 
in  the  immediate  neighbourhood  of  the  latter,  and  the  absence  of  any  con- 
tinuity of  abnormal  growth  between  the  two  masses  of  infiltration  was  very 
clearly  marked.  The  symmetrical  arrangement  of  the  double  infiltration 
in  the  two  eyes,  and  what  might  be  called  their  symmetrical  independence, 
was  of  considerable  interest. 

A  third  point  of  interest  was  the  cyst  in  front  of  the  trachea,  the  exist- 
ence of  which  had  not  been  recognized  before  death.  This  cyst  had  no 
connection  with  the  thyroid  body  or  trachea,  and  had  probably  existed 
for  some  time,  perhaps  years,  if  we  may  judge  from  the  presence  of  the 
calcareous  plates  upon  the  inner  surface  of  its  walls.  The  exact  pathology 
of  the  cyst  it  is  very  difficult  to  determine.  There  were  no  signs  of  inter- 
ference in  the  functions  of  either  trachea  or  oesophagus  during  life,  so  that 
its  rate  of  growth  is  unknown.  In  view  of  the  constitutional  syphilis,  its 
origin  had  been  probably  a  gummy  deposit  in  the  subcutaneous  tissue  of 
the  neck,  just  below  the  isthmus  of  the  thyroid  and  in  front  of  the  trachea, 
which  had  subsequently  undergone  retrograde  metamorphosis.  Its  con- 
tents found  at  the  autopsy  were  regarded  as  disintegrated  clots,  but  the 
presence  of  the  blood  may  be  accounted  for  by  the  marked  hemorrhagic 
diathesis.  The  wall  of  the  cyst  varied  from  three  to  five  lines  in  thick- 
ness; its  inner  surface  was  smooth,  as  if  covered  by  a  membrane,  except 
where  the  calcareous  plates  were  situated,  and  the  outer  surface  rough, 
owing  to  adhesions  to  the  surrounding  tissues.  Microscopic  sections 
showed  that  there  was  no  distinct  lining  membrane,  nor  any  trace  of  epi- 
thelium, and  the  smooth  appearance  of  the  inner  surface  was  probably  the 
result  of  pressure  of  the  contents.  The  wall  was  composed  of  a  large 
number  of  layers  of  fibro-areolar  tissue,  with  some  cells,  fusiform  and 
round,  with  nucleus  and  granular  contents.  These  layers  of  fibres  were 
packed  very  closely  together,  forming  a  dense  strong  wall,  which  had 
probably  originated  in  the  following  way :  A  gummy  deposit  had  occurred 
in  the  subcutaneous  areolar  tissue,  which,  by  its  presence,  had  set  up  a 
localized  inflammation,  lymph  was  poured  out  around  the  gumma,  became 
organized,  and  thus  the  growth  went  on.  At  some  subsequent  period  the 
contents  of  the  tumour  began  to  break  down,  disintegrated  and  perhaps 
suppurated,  and  at  this  stage  the  hemorrhage  may  have  occurred,  and 
mingled  with  the  contents.  As  the  process  of  absorption  went  on,  these 
bloody  extravasations  probably  recurred  again  and  again,  and  thus  the 
cyst  wall  had  no  opportunity  of  collapsing,  and  hence  no  obliteration  of  the 
cavity  occurred. 

The  accompanying  eruption  was  another  interesting  feature  in  the  case. 
Its  ill-defined,  nondescript  character  was  at  first  unsatisfactory.    The  spots 
were  as  often  pustules  as  vesicles,  and  even  when  more  truly  vesicular  the 
surrounding  areola  was  different  from  that  usually  seen  in  this  variety  of 
No.  CLII  Oct.  1878.  27 


418 


Schell,  Cause  and  Prevention  of  Squint. 


[Oct. 


eruption.  Only  in  a  few  of  the  spots  was  the  areola  at  all  well  marked, 
and  the  vesicles  were  not  large  enough  to  speak  of  them  as  bulla3  until 
towards  the  close  of  life.  The  ill-defined  character  of  the  eruption  was  no 
doubt  the  sign  of  a  lack  of  development,  due  to  the  extremely  low,  maras- 
mic  state  of  the  man's  system.  As  a  rule  patients  with  pemphigus  die  of 
marasmus,  and  very  often  from  pulmonary  tubercles  or  pneumonia.  In 
many  cases  we  also  find  at  the  autopsy  amyloid  degeneration  of  the  liver, 
spleen,  and  kidneys,  with  chronic  interstitial  desquamative  nephritis.  The 
locality  of  the  eruption  was  also  somewhat  singular.  According  to  authori- 
ties, the  favourite  place  for  pemphigus  is  on  the  palm  of  the  hand  and  sole 
of  the  foot,  on  the  scalp  and  brow.  But  in  this  case  the  eruption  was  on 
the  face  below  the  forehead,  and  on  the  dorsum  of  the  hands  and  fingers. 
The  scars  on  the  back  and  abdomen  might  point  to  either  a  papular  or 
tubercular  eruption.  As  a  rule  scars  do  not  give  any  absolutely  character- 
istic sign  by  which  to  recognize  the  preceding  destructive  process,  though 
we  are  sometimes  assisted  by  them  in  coming  to  a  conclusion  as  to  the 
nature  of  the  lesion. 

The  final  point  of  interest  was  the  hemorrhagic  diathesis,  as  shown  by 
the  tendency  to  bleed  from  mucous  and  cutaneous  surfaces  on  slight  provo- 
cation, and  towards  the  end  spontaneously.  This  was  marked  from  the 
beginning.  The  buccal  mucous  membrane  and  tongue  were  pale  and  almost 
bloodless,  and  the  patient  had  frequently  had  epistaxis.  Subsequently  his 
gums  became  spongy  and  bled  easily;  attacks  of  epistaxis  occurred;  a 
bloody  diarrhoea  made  its  appearance,  and  was  with  difficulty  controlled, 
recurring  again  and  again  towards  the  end.  The  eruption  became  hemor- 
rhagic, and  even  at  first  the  contents  of  the  vesicles  or  pustules  was  in  part 
blood.  As  the  vesicles  became  bullae,  the  hemorrhagic  tendency  was  still 
more  clearly  developed. 


Article  IX. 

Cause  and  Prevention  of  Squint.  By  H.  S.  Schell,  M.D.,  Surgeon  to 
Wills  [Ophthalmic]  Hospital,  and  Ophthalmic  Surgeon  to  St.  Mary's  Hospital, 
Philadelphia. . 

The  operation  for  convergent  strabismus  has,  as  far  as  its  final  results 
are  concerned,  never  been  absolutely  satisfactory.  There  are  several  cir- 
cumstances which  may  justify  this  reservation,  either  from  a  cosmetic  or 
a  physiological  point  of  view.  In  the  first  place  it  is  not  always  easy  to 
obtain  a  perfect  parallelism  of  the  optic  axes ;  the  tendency  being  to  do 
either  too  much  or  too  little  in  the  way  of  tenotomy.    If,  however,  the 


1878.] 


Schell,  Cause  and  Prevention  of  Squint. 


419 


rectification  be  exact,  there  is  generally  left  a  disagreeable,  staring  appear- 
ance about  the  eve,  owing  to  a  sinking  of  the  lachrymal  caruncle.  This 
latter  etfect  depends  upon  a  contraction  of  the  subconjunctival  cellular 
tissue,  resulting  from  its  disturbance  by  the  hook  used  in  searching  for  the 
tendon,  and  is  obviously  not  easy  to  avoid.  But  even  supposing  that  the 
appearance  of  the  eye  after  the  operation  is  everything  that  could  be  de- 
sired, there  yet  remains  the  most  unfortunate  results  of  all,  in  that  we 
seldom  obtain  binocular  vision,  and  the  squinting  eye  is  for  the  most  part 
blind  or  nearly  so. 

In  order  to  avoid  the  necessity  for  the  operation,  however,  it  becomes 
necessary  to  examine  into  the  causes  of  strabismus.  In  the  great  majority 
of  instances  this  defect  is  connected  with,  and  apparently  dependent  upon 
the  existence  of  hypermetropia,  and  to  cases  of  this  character  it  is  proposed 
to  confine  the  attention  for  the  present.  The  manner  in  which  hyperme- 
tropia acts  in  causing  a  predisposition  to  squint  is  probably  as  follows.  It 
is  well  understood  that  in  the  ordinary  act  of  vision  there  is  a  constant 
relation  between  accommodation  and  convergence.  In  emmetropic  eyes, 
when  observing  distant  objects,  the  optic  axes  are  parallel  and  the  ciliary 
muscles  relaxed;  but  for  near  vision,  the  more  the  tension  of  the  ciliary 
muscles  is  increased  the  more  the  internal  recti  contract,  so  as  to  bring  both 
eyes  to  bear  upon  the  same  point.  Now  in  hypermetropic  eyes  the  ciliary 
muscles  must  be  kept  under  some  degree  of  tension  even  in  viewing  the 
distant  horizon,  and  the  internal  recti  have  a  tendency  to  contract  accord- 
ingly. When  such  eyes  are  focused  upon  a  near  object  the  accommoda- 
tion in  use  is  equal  to  that  required  by  emmetropic  eyes  for  the  same 
distance,  plus  the  amount  necessary  to  overcome  the  total  hypermetropia. 
In  like  manner  the  effort  at  convergence  would  be  equal  to  the  effort  at 
convergence  for  the  same  distance  in  emmetropia  plus  the  effort  which 
naturally  accompanies  the  ciliary  tension  required  to  overcome  the  hyper- 
metropia. Therefore,  if  the  desire  for  distinct  vision  is  greater  than  that 
for  binocular  vision,  the  tendency  is  constantly  towards  over-action  of  the 
internal  recti  and  too  great  convergence  of  the  optic  axes — in  other  words, 
to  convergent  strabismus.  This,  however,  mostly  occurs  in  mean  degrees 
of  hypermetropia,  because  in  high  degrees  it  is  impossible  to  obtain  distinct 
vision  with  any  effort.  As  vision  with  two  eyes,  however,  has  most  obvious 
advantages  over  vision  with  one,  the  external  recti  are  in  most  hyperme- 
tropes  brought  into  play  to  counterbalance  the  excessive  action  of  the 
interni;  so  that  although  a  large  proportion  of  the  community  are  hyper- 
metropes  (especially  in  childhood  when  strabismus  usually  first  makes  its 
appearance),  comparatively  a  small  number  acquire  squint. 

Badal  reports  that  20  per  cent,  of  all  the  cases  at  his  clinic  are  ametro- 
pic.  Of  these  30  per  cent,  have  hypermetropia  under  one  dioptric,  20  per 
cent,  from  1  to  2  D,  12  per  cent,  from  2  to  3  D,  and  5  per  cent,  from  3  to 


420 


Schell,  Cause  and  Prevention  of  Squint. 


[Oct. 


4  D.    Dr.  Emil  Emmert  has  examined  the  eyes  of  2148  students  of  from 

5  to  25  years  of  age,  in  the  Cantons  of  Bern,  Solothurn,  and  Neuenberg, 
and  found  that  of  this  number  76.2  per  cent,  were  hypermetropes.  J)r. 
Max  Conrad  examined  the  eyes  of  303G  students  of  from  6  to  1^  year-  of 
age,  in  Konigsberg.  He  states  that  at  6  years  of  age  70  per  cent.,  and  at 
18  years  23  per  cent,  are  hypermetropic.  As  the  number  of  children 
affected  with  strabismus,  however,  assumes  no  such  colossal  proportion-  as 
these,  it  is  evident  that  there  must  be  some  other  cause  than  mere  defi- 
ciency in  the  refractive  power  of  the  eye  concerned  in  the  production  of 
squint. 

Donders  thinks  that  the  turning  in  of  the  visual  organ  depends  to  some 
extent  upon  the  angle  between  the  visual  line  and  the  axis  of  the  cornea 
being  greater  in  squinting  hypermetropes  than  in  other  hypermetrope-  of 
the  same  degree.  The  difference  (1°)  which  he  assigns,  however,  would 
be  scarcely  perceptible,  and  it  is  difficult  to  imagine  that  it  could  have  so 
great  an  effect.  It  becomes  necessary,  therefore,  to  look  further  for  the 
cause.  Congenital  difference  in  the  degree  of  refraction  of  two  hyperme- 
tropic eyes  would  no  doubt  have  some  influence,  but  we  very  frequently 
meet  with  this  condition  in  people  who  do  not  squint. 

It  is  well  known  that  the  strength  of  the  ocular  muscles,  tested  by  their 
power  of  overcoming  prisms,  is  very  different  in  different  individuals.  The 
internal  and  external  recti  muscles  of  twenty  emmetropes  were  recently 
examined  in  this  way  by  the  writer  by  means  of  Nachet's  prisme  mobile. 
The  test-object  used  wras  the  upright  bar  of  a  window  sash  thirty  feet  dis- 
tant. The  prisme  mobile  affords  different  results  in  testing  the  muscles 
in  this  way  from  those  given  by  the  employment  of  ordinary  prisms.  In 
using  the  latter,  at  every  change  of  glasses  the  eye  relapses  to  its  straight 
position,  that  is  to  say,  the  optic  axes  become  parallel,  and  when  the  new 
prism  is  placed  before  the  eye  the  two  images  are  so  far  apart  that  often 
one  only  is  noticed,  and  there  is  no  desire  for  binocular  vision.  But  in  the 
use  of  the  prisme  mobile  the  increase  in  the  refractive  value  of  the  prism 
is  so  gradual  and  continuous  that  the  images  are  kept  superposed  until  a 
point  is  reached  where  the  over-acting  muscle  can  bear  the  strain  no  longer, 
and  the  two  images  become  suddenly  wide  apart.  It  will  be  found  that 
prisms  of  from  15  to  20  per  cent,  greater  strength  can  be  used  in  this  way 
with  retention  of  the  single  image  than  when  separate  prisms  are  used  in 
the  spectacle  frames.  In  testing  the  internal  rectus,  however,  it  was  fre- 
quently necessary  to  supplement  the  prisme  mobile  by  other  prisms.  The 
results  obtained  were  as  follows,  and  represent  the  amount  of  strain  each 
muscle  is  capable  of  in  its  efforts  to  satisfy  the  demand  for  binocular 
vision. 


1878.]  Schell,  Cause  and  Prevention  of  Squint.  421 


Cases  of  Emmetropes. 


No. 

Name. 

Prism  overcome 
by  internal 
rectus. 

Prism  overcome 
by  external 
rectus. 

Strength  of  ext. 
rectus  compared 
with  int.  rect. 
at  100. 

L.  C. 

34° 

4° 

12 

2 

N. 

34 

7 

20 

3 

T.  W.  E. 

34 

10 

30 

4 

F.  R. 

30 

16 

53 

o 

F.  E.  D. 

24 

Q 

S.  I.  S. 

20 

7 

35 

1 

B.  L.  L. 

16 

10 

62  ' 

Q 
o 

I.  M. 

14 

10 

71 

9 

G.  C.  H. 

43 

14 

10 

H.  E.  G'. 

17 

6 

35 

1 1 

S.  B. 

35 

5 

14  1 

12 

T.  D.  F. 

30 

7 

23 

13 

R.  R. 

25 

6 

24 

14 

F.  L.  N. 

32 

9 

28  ! 

15 

E.  1).  F. 

26 

7 

27 

16 

Mr.  B. 

30 

8 

27 

17 

R.  M. 

28 

8 

28 

18 

T.  M. 

36 

14 

39 

19 

Mrs.  D. 

28 

12 

43 

20 

Myself 

46 

13 

Average,  29° 

Average,  8|° 

Average,  28 

The  same  experiment  made  with  hypermetropes  (Ht  being  corrected 
in  each  case  by  the  appropriate  glass)  resulted  as  follows : — 

Cases  of  Hypermetropes. 


No. 

Name. 

Prism  over- 
come by  inter- 
nal rectus. 

Prism  over- 
come by  exter- 
nal rectus. 

Ht. 

Strength  of 
ext.  rect.  com- 
pared with  int. 

rect.  at  100. 

1 

C.  N.  T. 

32° 

10° 

i 

1  4 

31 

2 

N.  S 

18 

7 

39 

3 

B.  C. 

22 

12 

4V 
i 

55 

4 

I.  D. 

14 

7 

50 

5 

M.  C. 

30 

13 

1 
4 

43 

6 

A.  A. 

25 

12 

t's 

48 

7 

A.  K. 

16 

10 

it 

62 

8 

M.  C. 

30 

13 

-h 

43 

9 

Mrs.  B. 

29 

13 

45 

10 

P.  J.  H. 

30 

10 

h 

33 

11 

E.  M. 

38 

12 

32 

12 

L.  S. 

28 

14 

h 

50 

13 

L.  D. 

17 

16 

1 

4£ 

94 

14 

A.  H. 

19 

12 

63 

15 

W.  G. 

14 

12 

\ 

86 

16 

M.  S. 

30 

15 

h 

50 

Av.  25° 

Av.  12° 

Av.  48 

422 


Schell,  Cause  and  Prevention  of  Squint. 


[Oct. 


It  will  be  seen,  from  an  examination  of  these  lists,  that  the  strength  of 
individuals  varies  as  much  in  their  ocular  as  in  other  muscles  of  their 
bodies,  and  that  in  addition,  the  relative  strength  of  these  ocular  muscles, 
as  compared  with  one  another,  is  liable  to  great  variation  in  different  per- 
sons, although  we  might  suppose,  a  priori,  that  their  comparative  force 
would  be  nearly  constant. 

Taking  the  last  column  of  figures  in  each  table  as  the  basis  of  calculation, 
we  find  that  the  relative  strength  of  the  external  rectus  as  compared  with 
the  internal,  valued  at  100,  averages  28  in  emmetropes  and  48  in  hyper- 
metropes.  The  weakest  external  rectus  among  the  emmetropes  =  12, 
among  the  hypermetropes  =  31. 

It  would  seem  further,  that  in  hypermetropia  there  is,  with  unusual 
development  of  the  ciliary  muscle,  a  corresponding  power  of  the  external 
rectus  in  order  to  counterbalance  the  sympathetic  effect  of  the  former  upon 
the  interims,  and  that  failing  this  increased  strength  in  the  externus  we 
must  naturally  expect  to  have  strabismus.  The  hypermetropes  who  will 
retain  binocular  vision  are  those  who  start  in  life  with  external  recti  equal 
to  or  stronger  than  the  average.  Those  who  will  acquire  squint  have  the 
external  recti  weaker  than  the  average. 

According  to  Donders  strabismus  generally  arises  about  the  fifth  year, 
but  sometimes  as  late  as  the  eighteenth.  The  former  of  these  ages  evi- 
dently points  to  the  commencement  of  the  methodical  employment  of  the 
eyes  upon  near  work,  as  in  learning  to  read,  etc.,  and  of  course  involves, 
in  hypermetropes,  extra  strain  of  the  accommodation  and  the  results  hereto- 
fore described.  On  the  other  hand,  a  squint  is  often  reported  by  the  parents 
of  the  child  to  have  originated  in  an  attack  of  measles  or  other  illness. 
Here,  when  the  whole  body  is  weakened  by  disease,  the  child  commences 
to  tax  its  eyes  too  early  during  convalescence.  The  external  rectus  being 
naturally  weaker  than  the  internal,  and  now  still  further  reduced  in 
strength,  easily  succumbs  before  the  interims,  when  the  latter  sympathizes 
with  a  great  effort  made  by  the  weakened  ciliary  muscle  to  compensate  for 
a  deficient  refractive  power.  As  convalescence  progresses  and  health  and 
strength  become  fully  restored,  the  external  rectus  may,  and  often  does 
become  rehabilitated,  exercises  its  full  power,  and  the  squint  disappears. 
But  it  often  persists. 

There  is  generally  a  period  in  all  cases  of  strabismus  when  the  excessive 
convergence  is  only  observable  during  near  vision.  In  distant  vision  the 
optic  axes  are  parallel.  Soon  the  squint  is  noticeable  as  well  in  distant  as 
in  near  vision.  It  is  now  often  alternating.  Sometimes  one  eye  is  used, 
sometimes  the  other,  and  both  are  in  this  way  exercised.  Or  one  may  be 
used  for  near  and  the  other  for  distant  sight.  This  is  esjDecially  apt  to 
happen  if  the  degree  of  hypermetropia  is  greater  in  one  eye  than  in  the 
other.  Soon,  however,  the  patient  gets  into  the  habit  of  using  one  eye 
only ;  then  the  disused  one  becomes  less  and  less  sensitive  to  the  rays  of 


1878.] 


S  c  h  e  l  l  ,  Cause  and  Prevention  of  Squint. 


423 


light  until  it  is  finally  nearly  or  quite  blind.  Now  a  curious  change  often 
takes  place.  No  further  calls  are  made  for  exertion  upon  the  ciliary 
muscle ;  the  internal  rectus  relaxes  accordingly,  the  external  rectus  asserts 
itself;  the  strabismus  commences  to  disappear,  and  parents  and  friends 
remark  that  the  eyes  are  getting  well  of  themselves.  "  The  child  is  grow- 
ing out  of  its  squint."  But  if  the  vision  is  now  tested,  the  eye  will  be 
found  blind.  When  a  child  is  said  to  be  growing  out  of  its  squint,  it 
simply  means  that  it  is  becoming  blind  in  the  squinting  eye. 

The  obvious  treatment,  then,  for  hypermetropic  strabismus  is  to  prevent 
its  becoming  confirmed  by  putting  correcting  glasses  on  the  child  while 
the  visual  axes  are  yet  parallel  for  distant  vision.  I  have  done  this  in  a 
number  of  cases  with  most  satisfactory  results.  In  some  instances  the 
children  were  not  more  than  five  years  of  age.  Of  course  there  are  many 
objections  which  will  be  raised  against  such  a  plan  of  treatment.  Of  these, 
the  great  liability  to  breakage  of  the  glasses  and  perhaps  to  injury  of  the 
eyes  in  the  accidental  falls  to  which  children  are  so  liable,  the  absurdity 
of  the  child's  appearance,  and  the  difficulty  of  getting  children  to  wear 
spectacles  are  the  oftenest  urged.  The  liability  to  breakage  is  chiefly  a 
question  of  expense  which  parents  must  decide  for  themselves.  I  have 
not  yet  seen  a  case  of  injury  to  the  eye  incurred  in  this  way.  As  to  ap- 
pearances it  is  surely  better  to  sacrifice  something  of  appearance  to  the 
preservation  of  sight.  As  to  the  last  objection,  I  have  generally  found 
that  if  the  degree  of  hypermetropia  is  moderately  large,  and  the  child  fairly 
intelligent,  it  is  usually  delighted  with  the  glasses,  and  has  no  disposition 
to  throw  them  aside.  In  cases,  however,  where  for  various  reasons  glasses 
cannot  be  used,  we  must  resort  to  temporizing  measures  having  for  their 
object  the  preservation  of  the  normal  acuity  of  vision  in  the  squinting  eye. 
This  is  accomplished  by  putting  the  other  eye  under  the  influence  of  atro- 
pia  occasionally,  or,  still  better,  by  binding  it  up  for  a  few  hours  every  day, 
and  thus  forcing  the  child  to  use  the  squinting  one. 

The  figures  given  in  the  foregoing  tables  are,  of  course,  too  few  in  num- 
ber to  establish  an  absolute  average  of  strength  for  the  two  muscles-  in 
question,  either  in  emmetropia  or  in  hypermetropia.  It  is  claimed,  how- 
ever, that  they  do  serve,  as  far  as  they  go,  to  illustrate  the  difference  in 
the  two  conditions;  for  they  are  taken  just  as  they  came,  are  all  cases  of 
adults,  and  no  case  is  omitted  that  was  tested.  It  is  perhaps  not  venturing 
too  much  to  say  that  if  the  list  of  persons  reported  as  emmetropic  had 
been  instead  hypermetropic,  it  would  not  have  been  difficult  to  pick  out 
those  who  would  have  been  liable  to  acquire  strabismus.  They  would 
probably  have  been,  under  favourable  circumstances,  Nos.  1,  2,  9,  11, 
and  20. 

The  conclusions  which  seem  to  be  justified  by  the  argument  in  this 
paper  may  be  formulated  as  follows : — 

1.  Convergent  strabismus  occurs  in  those  cases  of  hypermetropia  where 


424  Duhring,  Case  of  the  So-called  Xeroderma.  [Oct. 

the  external  recti  muscles,  as  compared  with  the  internal  recti,  are  weaker 
than  the  average. 

2.  To  prevent  it,  and  the  consequent  amblyopia,  we  must  use  glasses 
to  correct  the  total  hvpermetropia  as  soon  as  the  squint  makes  its  appear- 
ance. 


Article  X. 

A  Case  of  the  so-called  Xeroderma  (or  Parchment  Skin)  ofHebra.1 
By  Louis  A.  Duhring,  M.D.,  Professor  of  Skin  Diseases  in  the  University 
of  Pennsylvania,  Dermatologist  to  the  Philadelphia  Hospital,  and  Physician 
to  the  Dispensary  for  Skin  Diseases. 

The  disease  of  which  the  following  case  is  an  example  is  of  such  rare 
occurrence  that  any  information  respecting  it  must  prove  interesting  and 
valuable.  But  very  few  cases  have  been  recorded,  and  these  quite  lately, 
so  that  until  a  recent  date  no  account  of  the  disease  whatever  existed. 
The  case  before  us  differs  in  several  points  from  those  which  have  been 
described  by  Hebra  and  Kaposi  and  by  Taylor,  to  which  I  shall  refer 
later,  and  shows  that  the  affection  is  not  necessarily  accompanied  by  such 
marked  symptoms  of  atrophy  as  occurred  in  the  two  cases  related  by 
Hebra  and  Kaposi. 

The  patient,  Annie  McC,  is  a  young  woman,  aged  seventeen,  of  Irish 
parentage.  Her  father  is  living  and  is  healthy  ;  her  mother  is  deceased, 
and  is  said  to  have  died  of  cancer  of  the  womb.  She  has  three  brothers 
and  one  sister  living,  and  had  four  other  sisters,  who  died  quite  young 
from  various  infantile  diseases.  Neither  parent,  nor  any  of  the  brothers 
or  sisters  exhibited  any  disease  of  the  skin.  There  is  no  history  of  con- 
sumption. 

According  to  the  statement  of  the  parents,  the  affection  made  its  appear- 
ance at  the  age  of  six  months,  upon  the  face,  more  particularly  over  the 
nose  and  cheeks,  in  the  form  of  ordinary  freckles.  At  birth  the  skin  Avas 
normal,  and  the  child  was  considered  healthy.  The  lesions  gradually 
spread  over  the  rest  of  the  face,  neck,  and  extremities,  increasing  in  num- 
ber from  year  to  year.  The  early  history  of  the  disease  cannot  be  ascer- 
tained more  minutely,  but  it  is  said  that  at  the  age  of  nine  years  the  lesions 
were  quite  as  extensively  distributed  and  as  well-marked  as  at  present, 
and  that  but  little  change  has  taken  place  since  this  date,  except  on  the 
face  and  on  the  backs  of  the  hands.  Three  years  ago,  when  working  in 
the  mill  and  using  some  strong-smelling,  offensive  oil  for  lubricating  the 
machinery,  there  appeared  on  the  upper  part  of  the  cheeks  about  a  dozen 
pin-head  sized,  solid,  "  reddish  pimples."  They  came  in  the  course  of  a 
week,  and  were  confined  to  the  cheeks.  Some  eight  girls  were  similarly 
occupied  with  the  machinery,  all  of  whom  were  affected  in  the  same  man- 

1  Read  at  the  Second  Annual  Meeting  of  the  American  Dermatol ogical  Association, 
at  Saratoga  Springs,  Aug.  1878. 


1878.] 


Duhring,  Case  of  the  So-called  Xeroderma. 


425 


rer.  The  eruption  disappeared  within  three  or  four  weeks  by  scaling  and 
slight  crusting,  and  was  succeeded  in  our  patient,  according  to  her  state- 
ment, by  the  pock-like  marks  which  still  remain  ;  but  as  far  as  she  knows 
none  of  the  other  mill-hands  were  thus  marked.  She  seems  positive  that 
the  cheeks  and  nose  were  badly  freckled  before  this  eruption  appeared,  and 
that  the  atrophic  marks  followed,  obliterating  in  a  great  measure  the  former 
freckles.  Within  the  past  tive  years  she  has  noticed  that  on  the  backs  of 
the  hands  the  freckles  have  been  here  and  there  very  slowly  and  gradually 
disappearing,  and  that  in  their  place  small  areas  of  thinned  whitish  skin 
have  come.  No  more  particular  information  concerning  the  lesions  can 
be  obtained. 

Present  Condition  The  patient  is  tall  and  spare.  She  has  dark -brown 

hair  and  eyes,  and  a  fair  skin  upon  the  unaffected  regions.  The  general 
nutrition  of  the  body  is  good,  the  trunk  and  extremities  being  supplied 
with  the  average  amount  of  adipose  tissue.  The  general  health  is  fair, 
and  the  various  functions  are  normal.  The  sudoriparous  system  acts  freely, 
but  the  sebiparous  glands  are  somewhat  sluggish  in  their  action.  The 
hair  and  nails  are  healthy,  likewise  the  tongue  and  mucous  membrane. 

The  disease  occupies  the  scalp,  face,  ears,  neck,  chest,  back,  shoulders, 
arms  and  forearms,  backs  of  hands  and  fingers,  legs  and  backs  of  feet.  It 
consists  of  an  extensive,  well-marked,  disseminated,  deposition  of  pigment, 
in  the  form  of  pin-head  to  split-pea  sized,  yellowish,  brownish,  and  black- 
ish, freckle-like  lesions,  together  with  the  occurrence  here  and  there  of 
minute  linear  or  rounded,  pin-head  sized  telangiectases,  and  pin-head  and 
split-pea  sized,  whitish,  more  or  less  defined,  atrophic  spots.  There  exist 
therefore  three  kinds  of  lesions  to  be  considered,  namely,  pigmentary, 
telangiectasic,  and  atrophic. 

The  pigmentary  deposit  is  very  decidedly  the  most  prominent  feature  of 
the  disease,  and  is  that  for  which  the  patient  sought  medical  advice.  All 
of  the  affected  regions  are  thickly  covered  with  what  appear  at  first  sight 
to  be  unusually  defined,  large  and  small,  light  and  dark  freckles,  giving 
the  skin  a  variegated,  checkered  look.  The  patient  and  her  family  believe 
the  disease  to  be  one  of  a  singular  form  of  freckles,  and  certainly  the 
appearance  is  such  that  no  other  view  would  be  entertained  by  any  one 
were  it  not  for  the  presence  of  the  other  lesions,  to  be  presently  described. 
The  lentigines,  or  freckles,  as  I  shall  designate  these  lesions  in  speaking 
of  them,  exist  in  profusion,  scarcely  a  portion  of  the  affected  regions  escap- 
ing. They  are  disseminated,  showing  no  regularity  of  distribution,  nor 
any  disposition  to  group.  They  are  scattered  over  the  surface  at  hap- 
hazard, as  in  the  case  of  ordinary  freckles.  They  are,  however,  as  will  be 
presently  described,  more  abundant  and  more  marked  in  some  localities 
than  in  others.  In  size  they  vary  from  a  small  pin-head  to  a  large  split-pea, 
the  majority  perhaps  averaging  the  size  of  large  pin-heads.  They  are  dis- 
crete or  confluent,  and  are  for  the  most  part  sharply  defined,  with  very 
irregular,  angular,  jagged  outlines,  which  cause  them  to  stand  forth  con- 
spicuously against  the  surrounding  healthy  skin.  Their  colour  varies  from 
light  yellow  to  black  ;  while  the  majority  are  of  a  dirty-yellowish,  brown- 
ish-yellow colour,  others  are  deep  browm  and  some  are  quite  black.  The 
blackish  lesions  are,  however,  exceptional.  The  pigment  is  distributed 
unevenly,  as  in  the  case  of  ordinary  lentigo. 

Concerning  the  telangiectases,  which,  it  may  be  here  stated,  are  by  no 
means  numerous,  it  is  observed  that  they  occur  here  and  there,  and  that 
they  exist  for  the  most  part  as  small,  ill-defined  lesions.    They  are  true 


426 


Du h ring,  Case  of  the  So-called  Xeroderma.  [Oct. 


telangiectases,  differing  in  no  way  from  those  encountered  independent  of 
other  disease.  They  are  made  up  of  a  congeries  of  capillaries.  They  are 
circumscribed  or  diffused,  flat,  raised,  or  slightly  rounded,  irregularly 
rounded,  angular  or  linear,  pin-head  and  even  smaller  sized,  bright  or 
deep  red  lesions.  They  are  met  with  here  and  there  over  the  whole  of 
the  invaded  surface,  but  are  most  distinctly  marked  about  the  neck  and 
chest.  They  are  nowhere  so  numerous  or  so  large  as  to  be  conspicuous, 
and  they  might  readily  be  overlooked  by  the  casual  observer,  or  be  re- 
garded simply  as  accidental  telangiectases.  Occasionally  only  are  they 
elevated,  and  seldom  so  to  any  extent,  the  majority  being  on  a  level  with 
the  surrounding  skin. 

The  atrophic  spots,  like  the  telangiectases,  are  few  and  scattered,  occur- 
ring here  and  there  in  between  the  freckles.  They  consist  of  pin-head 
and  split-pea  sized,  rounded  or  irregularly  shaped,  somewhat  glistening, 
whitish  lesions.  They  bear  resemblance  to  the  marks  of  varicella  or  of 
variola,  but  they  are  more  irregular  in  outline,  more  superficial,  and  less 
circumscribed  and  sharply  defined.  Taken  between  the  fingers  the  skin 
is  noted  to  be  slightly  thinned,  to  be  soft  and  supple,  and  to  have  a  smooth, 
polished  surface,  like  glazed  paper.  The  skin  can  be  readily  pinched  up. 
Some  of  the  lesions  can  be  detected  in  passing  the  hand  over  them  ;  in 
other  places  they  are  barely  or  not  at  all  perceptible  to  the  touch.  Their 
shape  and  size  in  many  instances  are  those  of  their  neighbouring  freckles. 
Here  and  there,  as  on  the  baeks  of  the  hands,  there  exist  large,  split-pea 
sized,  irregularly  shaped  patches  of  atrophied  skin,  the  result  of  several 
adjoining  lesions  having  undergone  simultaneous  atrophy.  The  atrophy 
of  the  skin,  however,  viewing  the  process  of  atrophy  as  a  whole,  is  insig- 
nificant, and  is  in  some  places  so  slight  as  to  be  scarcely  appreciable. 

The  sensibility  of  the  skin  is  not  diminished.  There  are  no  feelings  of 
contraction,  stretching,  or  tightness  of  the  skin.  There  are  no  subjective 
symptoms  whatsoever. 

Having  thus  given  a  general  description  of  the  disease,  we  may  examine 
more  closely  the  several  regions  invaded,  pointing  out  any  peculiarities 
that  may  be  worthy  of  mention.  The  hair  of  the  head  is  dry,  but  not 
remarkably  so.  The  scalp  is  free  of  seborrhcea.  It  is  well  covered  with 
disseminated  freckles,  which  give  it  a  dirty  appearance,  and  which  look 
like  small  collections  of  dirty  sebaceous  matter.  They  occupy  the  whole 
of  the  scalp,  but  are  not  so  profuse  as  upon  the  face  and  other  regions. 
They  are  in  greatest  numbers  over  the  vertex  and  on  the  parietal  regions. 
About  the  occiput  they  are  thinly  scattered.  They  differ  in  no  way  from 
those  on  the  face,  to  be  presently  described.  Here  and  there  occur  small 
telangiectases,  some  of  which  are  typically  developed,  while  others  are  in  a 
shrunken  state,  and  apparently  passing  into  atrophic  spots.  Well-marked, 
complete  atrophic  lesions  exist  only  here  and  there  ;  several  are  observed 
in  the  median  line  where  the  hair  is  parted. 

The  face  is  well  sown  with  freckles  of  all  colours,  but  it  is  by  no  means 
so  extensively  invaded  as  the  neck,  chest,  back,  or  arms;  nor  are  the 
lesions  here  as  large  as  on  the  regions  just  specified.  They  are  least 
numerous  upon  the  nose  and  upper  part  of  the  cheeks,  where  exist  distinct, 
mostly  superficial,  atrophic  marks,  varying  in  size  from  a  large  pin-head 
to  a  split-pea.  These  lesions  are  the  most  pronounced  of  any  of  the  atro- 
phic ones,  and  are  about  as  conspicuous  as  small  variola  scars,  which  indeed 
they  resemble  in  size  and  in  form,  as  well  as  in  the  amount  of  cicatricial 
tissue.    There  are  about  a  dozen  of  them.    They  show  no  regularity  of 


1878.]         Dun  ring,  Case  of  the  So-called  Xeroderma. 


427 


arrangement.  The  history  of  these  lesions,  it  will  be  remembered,  is  not 
perfectly  clear,  but  there  is  every  reason  to  believe  that  they  are  the  result 
of  the  disease  under  consideration,  and  not  of  the  accidental  eruption 
referred  to.  The  telangiectases  on  the  face  are  few,  small,  and  ill-detined, 
and  occur  for  the  most  part  on  the  upper  half  of  the  cheeks.  They  number 
about  a  dozen,  but  only  three  or  four  are  of  any  size,  the  rest  being  quite 
small  and  indistinct  in  outline.  One  of  the  largest  is  situated  on  the  right 
temporal  region.  It  is  raised,  and  is  about  the  size  and  shape  of  a  cara- 
way seed,  and  of  a  bright  red  colour. 


The  neck,  back,  and  chest  are  thickly  dotted  with  pigmentary  lesions, 
some  of  which  are  remarkably  large.  Over  the  back  they  are  found  as  low 
down  as  the  lumbar  vertebras,  but  below  the  line  of  the  scapulas  they  are 
only  thinly  scattered,  small,  and  faint  in  outline  and  in  colour.  Over  the 
chest  they  are  numerous,  but  are  no  different  in  character  from  those  on 
the  face  or  back.  They  fade  away  over  the  upper  portion  of  the  mammas, 
none  or  very  few  existing  below  the  line  of  the  nipples.  The  lower  por- 
tion of  the  thorax  and  the  abdomen  are  entirely  free,  the  skin  being  nor- 
mal and  quite  fair.  The  telangiectases  are  more  numerous  on  the  neck 
than  on  the  face,  appearing  for  the  most  part  as  small  pin-head  sized, 
irregularly-shaped  flat  lesions,  some  of  them  evidently  undergoing  atrophic 
change.     They  are  especially  noticeable  about  the  clavicles.  Atrophic 


428 


Duhring,  Case  of  the  So-called  Xeroderma.  [Oct. 


marks  exist  here  also,  but  they  are  small.  Upon  the  back  of*  the  Deck 
and  over  the  back  both  the  telangiectases  and  atropine  lesions  are  very 
insignificant. 

The  shoulders,  arms,  forearms,  and  backs  of  hands  and  fingers  are 
thickly  studded  with  freckles,  being  present  almost  in  sheet,  and  give  a 
decidedly  variegated,  checkered  look  to  the  skin.  The  extensor  surfaces 
are  especially  attacked.  The  regions  of  the  axilla?  and  the  upper  half  of 
the  arms  are  comparatively  free.  The  extensor  surfaces  of  the  forearms, 
backs  of  hands,  and  fingers  are  particularly  well  marked  with  freckles  of 
large  size,  and  mostly  dark  in  colour.  Some  are  as  large  as  large  split- 
peas  ;  these  stand  out  quite  conspicuously,  and  are  noted  to  be  situated  at 
irregular  intervals  one  from  another  of  from  one  to  two  inches.  Upon  the 
backs  of  the  fingers  they  extend  as  far  down  as  the  nails.  The  flexor  sur- 
faces of  the  fingers  and  the  palms  are  entirely  free  The  telangiectases  are 
rare  over  the  arms  and  forearms,  but  are  commoner  upon  the  backs  of  the 
hands,  where  they  are  small,  flat,  chiefly  of  a  linear  form,  and  indistinctly 
defined.  The  atrophic  marks,  however,  are  numerous,  and  are  better 
defined  here  than  elsewhere,  occurring  here  and  there  as  irregularly  shaped, 
split-pea  sized  areas  of  thinned,  smooth,  whitish  skin.  Taken  between  the 
fingers  the  skin  can  be  felt  to  be  thinned,  but  not  in  a  striking  degree.  The 
atrophy  is  of  the  most  superficial  character,  involving  plainly  only  the 
uppermost  strata  of  the  skin.  The  condition  is  not  unlike  the  senile  atro- 
phy often  met  with  in  patches  on  the  backs  of  the  hands  of  old  men  who 
have  been  exposed  to  an  outdoor  life.  The  patient  is  not  aware  how  long 
these  atrophic  lesions  have  existed,  but  she  remembers  that  formerly  the 
backs  of  the  hands  were  much  more  freckled  than  now,  and  she  states  that 
the  whitish,  cicatricial  areas  have  developed  very  gradually  through  a 
period  of  years.  She  does  not  recall  ever  having  observed  telangiectases 
here,  but  inasmuch  as  she  is  far  from  being  a  close  observer  they  may 
nevertheless  have  preceded  the  present  lesions,  which,  I  think,  was  with- 
out doubt  the  case. 

The  buttocks  and  thighs  are  free  of  disease,  but  the  lesions  again  showr 
themselves  sparsely  about  the  knees.  The  legs,  especially  the  extensor  sur- 
faces, from  the  knees  to  the  ankles,  and  the  backs  of  the  feet,  are  invaded 
with  pigmentary  lesions  only.  No  telangiectases  nor  atrophic  spots  are  to 
be  found.  The  freckles  are  numerous,  but  are  much  smaller,  less  distinct 
in  outline,  and  lighter  in  colour  than  those  on  the  arms.  The  backs  of  the 
toes  and  the  soles  are  not  involved. 

Remarks  We  have  in  the  disease  under  consideration  unquestionably 

a  very  rare  manifestation.  The  case  described  is  the  first  example  of  the 
affection  that  I  have  met  with  in  Philadelphia.  Some  few  months  since, 
through  the  courtesy  of  Dr.  K.  AY.  Taylor,  of  New  York,  I  had  the  oppor- 
tunity of  carefully  examining  three  other  cases  of  the  same  disease,  residing 
in  New  Y"ork.  These  cases  are  well  known  to  several  dermatologists  of 
Newr  York,  and,  together  with  other  cases,  formed  the  basis  of  an  elabo- 
rate and  exhaustive  article  on  this  disease  by  Dr.  Taylor,  which  was  pre- 
sented at  the  first  annual  meeting  of  the  American  Dermatological  Asso- 
ciation, in  Sept.  1877.1 

1  The  article  has  unfortunately  not  as  yet  been  published,  and  I  am  therefore  de- 
barred from  referring  to  it  more  in  detail. 


1878.] 


Duhring .  Case  of  the  So-called  Xeroderma. 


429 


From  a  review  of  the  case  presented,  we  may  note  the  following  points 
of  interest.  In  the  first  place,  the  early  age  at  which  the  disease  made  its 
appearance.  This  statement  is  entirely  in  accord  with  the  history  of  both 
Hebra's  and  Taylor's  cases,  the  disease  in  every  instance  having  appeared 
in  early  life.  The  extremely  slow  evolution  of  the  symptoms,  and  the 
chronic  course  of  the  affection  as  a  process,  were  also  noted  in  the  above 
cited  cases.  As  has  been  already  stated,  the  pigmentary  lesions  differ  in 
no  essential  particular  from  common  lentigines.  The  patient  was  indeed 
on  several  occasions  treated  for  freckles.  The  lesions,  however,  are  not 
only  larger  but  are  much  more  deeply  pigmented  than  in  common  lentigo, 
the  blackish  lesions  being  singularly  conspicuous  and  peculiar.  The  telan- 
giectases present  nothing  unusual.  The  atrophic  marks  are  remarkable  for 
their  superficial  character,  the  atrophy  being  confined  to  the  uppermost  layers 
of  the  corium,  and  in  all  probability  not  extending  below  the  papillary 
layer.  They  may  be  compared  to  the  well-known  macula?  atrophica?,  but 
they  are  even  more  superficial,  and  are  less  markedly  circumscribed,  and 
less  conspicuous. 

The  relation  one  to  the  other  of  the  several  kinds  of  lesions  is  a  most 
interesting  topic.  From  the  history  of  the  case,  as  well  as  from  the  present 
appearance  of  the  lesions,  it  may,  I  think,  be  considered  as  pretty  clearly 
established  that  the  following  course  is  the  usual  one.  The  pigmentary 
bpots  are  the  first  symptoms,  which  in  a  variable  time  are  here  and  there 
succeeded  by  the  development  of  telangiectases,  occupying  as  a  rule  the 
whole  or  greater  portion  of  the  freckle.  They  continue  for  a  longer  or 
shorter  period,  when  they  begin  to  contract  and  undergo  atrophy,  finally 
disappearing,  to  be  followed  by  the  atrophic  macules.  As  the  telangiec- 
tases happen  to  be  small  or  large,  superficial  or  deeper-seated,  will  the  sub- 
sequent atrophic  spots  be  slight  or  extensive,  superficial  or  deeper. 

Viewed  from  a  pathological  standpoint  it  is  difficult  to  know  where  the 
disease  should  be  placed;  whether  among  the  pigment  hypertrophies,  with 
the  new  growths,  or  with  the  atrophies.  Hebra  and  Kaposi  kave  regarded 
the  affection  as  an  atrophy,  and  have  considered  it  under  the  head  of  the 
diffused  idiopathic  atrophies,  along  with  senile  atrophy.  They  have  given 
to  it  the  name  "xeroderma,"  or  "parchment  skin,"  a  name  which,  how- 
ever, as  will  I  think  be  admitted,  is  by  no  means  appropriate  to  the 
phase  of  the  disease  represented  by  the  case  under  consideration.  In  their 
work  on  diseases  of  the  skin1  they  give  brief  notes  of  two  cases  which  had 
fallen  under  their  observation,  and  refer  in  a  few  lines  to  two  other  cases 
that  they  had  seen,  being  the  whole  material  from  which  their  knowledge 
of  the  disease  is  drawn.  These  cases  constitute,  I  believe,  the  only  exam- 
ples of  the  affection  that  have  been  published.  In  Hebra's  and  Kaposi's 
cases  (both  girls,  eighteen  and  ten  years  of  age,  in  both  of  whom  the  dis- 


1  New  Syd.  Soc.  Transl.,  vol.  iii.  p.  252. 


430 


Duhring,  Case  of  the  So-called  Xeroderma. 


ease  had  existed  since  early  childhood),  the  process  assumed  a  much 
severer  type  than  in  my  case,  the  atrophy  being  marked  and  extensive. 
Kaposi  thus  speaks  of  the  atrophy  in  the  first  case,  aged  eighteen :  The 
skin  "  was  also  tightly  stretched,  as  if  contracted,  was  pinched  up  into  a 
fold  with  difficulty,  and  felt  very  thin.    Its  surface  was  smooth  in  some 
places,  whilst  in  others  fine  epidermic  lamella?  peeled  off;  or  there  were 
quite  flat,  linear  furrows  marked  out  on  the  epidermis,  so  that  the  surface 
appeared  as  dry  as  parchment,  and  wrinkled,  whilst  the  skin  itself  was 
tightly  stretched."    Concerning  the  atrophy  in  the  second  case,  it  is  stated 
that  "  the  epidermis,  especially  on  the  eyelids  and  on  the  cheeks,  was 
wrinkled  and  shrivelled,  the  upper  eyelids  being  in  consequence  drawn 
somewhat  downwards,  and  the  lower  ones  drawn  down  and  everted,  the 
eyes,  therefore,  seeming  from  above  too  small,  and  from  below  incom- 
pletely covered.    In  the  same  way  the  oral  and  nasal  apertures  were 
somewhat  diminished.    In  addition,  the  skin  was  moderately  tense,  and 
was  less  readily  than  normally  pinched  up  into  a  fold,  but  this  could  always 
be  accomplished.    The  subcutaneous  layer  of  fat  was  not  altered."   It  will 
thus  be  seen  that  the  atrophy  formed  a  most  important  symptom  in  these 
two  cases,  a  symptom,  however,  which  was  by  no  means  either  extensive 
or  striking  in  my  case  ;  nor  was  there  any  indication  of  the  process  assum- 
ing any  proportions  similar  to  those  presented  in  Hebra's  and  Kaposi's 
cases.     In  three  of  Taylor's  cases,  those  that  I  saw,  the  atrophy,  while 
more  extensive,  still  manifested  the  same  general  characters  noted  in  my 
case.    It  is  therefore  manifest  that  the  term  xeroderma  is  altogether  in- 
appropriate for  the  stages  of  the  disease  represented  by  the  present  case. 
It  is,  moreover,  unfortunate  that  the  term  xeroderma  should  have  been 
selected  for  this  new  disease,  inasmuch  as  this  word  has  for  some  years 
been  in  use  as  signifying  a  mild  form  of  ichthyosis,  and  is  in  this  sense 
employed  to-day  by  many  writers,  both  abroad  and  in  this  country.  While 
it  is  admitted  that  the  atrophy  of  the  skin  is  an  important  Mature,  and  in 
some  cases  the  gravest  symptom,  in  the  course  of  the  disease,  it  is  also 
clear  from  a  study  of  the  case  just  considered  that  it  is  not  necessarily  the 
most  prominent  symptom.    The  pathological  process  is,  as  we  have  seen, 
a  complex  one,  including  hypertrophy,  atrophy,  and  new  growth.    In  view 
of  this  association  of  several  distinct  processes,  occurring  simultaneously 
or  consecutively,  it  becomes  extremely  difficult  to  place  the  disease,  and 
also  to  name  it.    Until  our  knowledge  concerning  it  is  more  complete,  it 
will,  I  think,  be  well  to  postpone  the  adoption  of  any  final  nomenclature. 

As  regards  treatment,  I  am  able  to  say  but  little.  Locally  the  pigmen- 
tary lesions  may  doubtless  be  treated  with  more  or  less  success  by  means 
of  the  well-known  remedies  used  against  lentigo  ;  while  the  telangiectases 
may  be  removed  with  a  solution  of  caustic  potash  (5j  to  as  in  the  case 
of  other  small  telangiectases. 


1878.]    Mills,  Vaso-motor  and  Trophic  Affection  of  Fingers.  431 


Article  XI. 

Vaso-Motok  and  Trophic  Affectiox  of  the  Fixgers.  By  Charles 
K.  Mills.  M.D.,  Neurologist  to  the  Philadelphia  Hospital,  Lecturer  on  Elec- 
tro-Therapeutics in  the  University  of  Pennsylvania. 

The  following  case  is  believed  to  be  unique,  and  worthy  of  being  placed 
on  record. 

E.  J.,  a?t.  23,  single,  mill  hand.  Her  mother  died  of  consumption. 
She  was  well,  except  that  she  was  troubled  with  sweating  of  the  hands  and 
feet  until  she  was  nineteen  years  old,  when  she  caught  a  severe  cold,  from 
which  she  suffered  several  weeks.  The  morbid  perspiration  ceased,  but 
she  began  to  have  cold  hands  and  feet,  and  about  this  time,  one  morn- 
ing in  early  autumn,  while  on  her  way  to  her  work,  the  little  finger  of  her 
left  hand,  as  far  as  the  second  joint,  suddenly  became  cold,  white,  and  numb. 
After  this  she  observed  that  when  exposed  to  cold,  one  or  more  fingers  or 
the  thumbs  would  get  into  a  similar  condition,  presenting  a  frost-bitten 
appearance.  Rubbing  energetically  would  cause  redness  and  a  sensation 
of  burning  which  would  last  half  an.  hour  or  longer. 

The  disorder  persisted,  growing  gradually  worse,  until  the  ends  of  all  her 
fingers  and  both  thumbs  were  more  or  less  involved.  Six  months  after  her 
little  finger  was  first  affected,  a  slight  swelling  formed  at  the  point  of  the  right 
thumb,  which  felt  as  if  a  splinter  had  run  into  it.  The  swollen  part  became 
red.  and  a  small  abscess  resulted,  which  after  being  poulticed,  soon  suppu- 
rated, but  left  a  sore  spot  for  many  weeks.  Similar  abscesses  appeared  from 
time  to  time  in  all  her  fingers  and  the  other  thumb  ;  sometimes  two  or 
even  three  occurred  at  once  on  different  fingers ;  and  on  some,  particularly 
the  index  and  middle,  they  recurred  several  times  at  intervals  of  two 
or  three  months.  The  first  attack  in  each  case  caused  great  pain,  but  on 
reappearing  the  suffering  was  less  severe.  Nearly  two  years  after  her 
fingers  were  first  affected,  she  began  at  times  to  notice  a  coldness  and 
numbness  in  the  forearms,  the  sensation  never  going  above  the  elbows,  and 
coming  on  usually  after  lying  down. 

She  came  under  my  care  early  in  June,  1878,  about  four  years  after  the 
first  trouble  with  her  finger-ends.  She  had  been  under  treatment  with  Dr. 
A.  Yan  Harlingen  for  about  a  year,  and  had  taken,  at  various  times,  cod- 
liver  oil,  iron,  strychnia,  chiretta,  quinia,  and  ergot.  Both  her  general  health 
and  the  condition  of  her  fingers  had  apparently  improved.  Abscesses  had 
occurred  less  frequently,  and  had  been  less  severe.  Every  now  and  then, 
however,  a  relapse  of  the  local  trouble  would  take  place,  the  blueness  and 
coldness  of  the  fingers  returning.  She  had  had  dyspeptic  symptoms ;  and 
in  April,  1878,  she  had  a  severe  "  cold,"  suffering  considerably  from  cough, 
dyspnoea,  and  pain  in  the  right  side. 

The  following  notes  on  the  case,  kindly  furnished  to  me,  were  made  by 
Dr.  Van  Harlingen  January  6,  1878:  The  weather  is  clear;  thermometer 
marking  22°  F.  The  patient  has  just  come  in  from  a  walk.  Her  hands 
are  stiff,  and  their  backs  to  the  wrist  of  a  violet  colour,  which  disappears 
under  pressure,  but  slowly  returns.  The  dorsal  surfaces  of  the  fingers  are 
white  ;  the  palmar  aspects  are  cyanosed,  as  are  also  the  hands,  but  to  a  less 
extent.  Her  fingers  feel  like  frozen  rods.  After  sitting  in  a  warm  room 
for  a  few  minutes,  her  hands,  and  particularly  her  fingers,  have  become 
mottled  red  and  white,  the  palms  perspiring  freely  but  not  excessively. 


432 


Mills,  Vasomotor  and  Trophic  Affection  of  Fingers.  [Oct 


On  putting  them  to  the  fire  they  tingle  and  burn.  They  always  act  in  this 
way,  and  have  to  be  warmed  gradually.  The  pulps  of  the  first,  little,  and 
middle  fingers  of  the  left  hand  are  somewhat  clubbed,  and  at  their  tips  Bhow 
a  pin's  head  circular  scar.  The  nail  of  the  little  finger  is  rough,  atrophied, 
and  blackened  towards  the  end.  This  nail  had  been  injured  by  an  iron 
falling  on  it  when  she  was  a  child ;  and  several  months  before,  after  one  of 
the  abscesses,  it  had  come  off,  but  had  been  reproduced.  It  can  be  lifted 
up  for  more  than  one-half  its  length  from  before  backwards.  The  finger 
around  it  is  tender.  The  other  nails  are  normal  in  appearance.  On  the 
right  hand,  only  the  thumb,  index,  and  middle  finger  show  the  puckered 
cicatrix.  The  middle  finger  is  decidedly  swollen  at  the  apex  and  around 
the  edge  of  the  nail ;  while  underneath  the  nail  a  little  suppuration  i<  going 
on,  apparently  from  the  external  and  distal  part  of  the  matrix.  Sensation 
is  almost  or  entirely  intact.  June  4,  1878,  Dr.  Van  Harlingen  noted: 
No  abscesses  are  present,  but  otherwise  her  hands  are  as  had  as  J  have  ever 
seen  them. 

These  notes  and  the  history  already  given  will  serve  to  afford  an  idea  of 
the  state  of  the  patient's  hands  before  she  was  seen  by  me  in  June.  Her 
hands  at  this  time  were  inclined  to  be  puffy,  and  her  finder  ends  were  cold 
and  numb.  Further  on  in  this  paper  I  will  give  the  results  of  some  thermo- 
metrical  observations.  They  varied  considerably  in  appearance  from  day 
to  day  :  when  worst  they  were  decidedly  blue  ;  when  best  they  were  bluish, 
white  or  dull  white.  The  muscles  of  her  hands  and  fingers  were  not  atro- 
phied, and  electro-contractility  was  not  impaired.  Sensibility,  tested  care- 
fully by  the  oesthesiometer,  was  very  good.  Electro-sensibility  was  .also 
retained.  Her  hands  were  improved  by  heat  and  made  worse  by  cold  ; 
they  were  also  better  when  used  and  exercised  than  when  at  rest. 

Examination  of  her  feet  showed  nothing  abnormal  in  colour  or  appear- 
ance, although  they  generally  felt  cold  to  the  patient. 

Holding  her  arms  above  her  head  caused  her  fingers  to  become  worse. 
On  several  occasions,  in  the  cold  weather,  irregular  patches  of  bright  red 
skin  appeared  here  and  there  over  her  hand,  showing  only  when  her  hand 
was  livid  with  cold,  and  presenting  a  curious  and  vivid  contrast  to  the  dark 
surrounding  surface.  Once,  after  dancing,  the  tip  of  her  tongue  became 
bluish-white,  and  her  tongue  felt  numb,  and  as  if  it  had  been  burned  with  hot 
tea  or  coffee ;  she  was  inclined  to  pinch  it  in  order  to  bring  back  its  proper 
feeling  ;  and  at  the  time  of  this  occurrence  she  experienced  also  a  little  dif- 
ficulty in  talking.  At  the  same  time  her  lips  became  bluish,  and  the  usual 
condition  of  her  hands  worse.  Any  fright  or  excitement,  or  damp  and 
chilly  weather,  will  produce  a  similar  effect,  but  generally  not  so  well 
marked  as  in  this  special  instance. 

Three  years  before  coming  under  observation  she  had  had  for  a  short 
time  a  form  of  "  asthma."  She  had  also  had  an  attack  of  what  her  physi- 
cian pronounced  to  be  congestion  of  the  lungs.  She  had  never  had  rheu- 
matism. She  rarely  suffered  from  headache,  and  never  from  giddiness. 
She  had  no  eye  or  ear  affection.  She  is  troubled  somewhat  frequently  wTith 
shortness  of  breath,  and  sometimes  with  slight  palpitations.  She  gene- 
rally sleeps  well,  and  has  a  variable  appetite.  Her  bowels  are  regular. 
Her  menses  are  regular  but  scant.  She  is  usually  pale,  her  lips  generally 
presenting  a  bloodless  appearance.  She  is  thin,  weighing  114  pounds.  Her 
work  is  weaving  in  colours  for  flannel  goods.  She  never  heard  of  any  one 
else  employed  in  the  same  way  being  similarly  affected. 

A  careful  examination  of  the  patient's  chest  was  made  by  Dr.  Roland  G. 


1878.]    Mills,  Vaso-motor  and  Trophic  Affection  of  Fingers.  433 


Curtin  and  myself.  Over  the  mitral  area  a  very  faint  presystolic  murmur 
was  heard.  The  impulse  was  increased.  After  exertion  a  marked  presys- 
tolic thrill  was  found.  It  may  be  needless  to  say  that  the  murmur  and 
thrill  convinced  us  of  the  existence  of  mitral  stenosis.  The  pulse  was  small 
and  frequent. 

Examination  of  the  lungs  showed  impaired  percussion  resonance  and 
vesicular  murmur  over  the  entire  right  side  of  the  chest,  with  friction 
sounds  about  the  junction  of  the  ribs  with  the  sternum.  Crackling  rales, 
changed  by  coughing,  were  heard  at  both  apices.  A  cavity  of  considerable 
size  was  discovered  at  the  right  apex. 

The  treatment  adopted  for  the  relief  of  the  local  manifestations  in  this 
case  was  entirely  electrical.  Three  methods  of  application  were  employed 
at  different  times,  viz.,  localized  faradization,  localized  galvanization,  and 
galvanization  of  the  brain  and  cervical  sympathetic  (so  called).  In  local- 
ized faradization  a  strong  current  was  applied  directly  to  the  fingers,  hold- 
ing one  rheophore  to  the  forearm,  wrist,  or  hand,  and  applying  the  other 
to  the  ends  and  every  part  of  the  fingers.  Moistened  rheophores  were 
usually  employed,  but  on  three  occasions  the  metallic  brush  was  used. 
In  localized  galvanization  the  current  was  sent  in  succession  through  each 
of  the  fingers,  placing  the  positive  rheophore  on  the  arm,  forearm,  or 
hand,  and  the  negative  on  the  tips  and  various  surfaces  of  the  fingers, 
using  also  a  strong  current.  Galvanization  of  the  brain  and  cervical 
sympathetic  (so  called)  was  performed  a  few  times  by  first  placing  the 
rheophores  on  the  mastoid  processes ;  and  next  holding  a  large  electrode 
over  the  sixth  and  seventh  cervical  vertebras,  and  a  smaller  one  in  the 
auriculo-maxillary  fossa,  first  of  one  side  and  then  of  the  other,  allowing 
in  each  case  a  weak  current  to  pass  for  from  two  to  three  minutes.  Usually 
five  or  six  cells  of  a  battery  in  good  condition  were  employed,  the  rheo- 
phores being  well  moistened.  Apparently  considerable  improvement  has 
taken  place  under  this  treatment,  the  patient's  fingers  having  a  much 
better  colour  and  general  appearance  than  when  first  seen  ;  but  it  will  be 
necessary  to  wait  for  the  cooler  weather  in  order  to  decide  as  to  the  per- 
manence of  the  effect.  She  is  better,  however,  than  she  was  at  the  same 
season  last  year.  The  treatment  has  been  chiefly  localized  galvanization 
and  faradization,  the  central  applications  having  only  been  used  two  or 
three  times.  She  has  received  twenty -four  applications  in  all.  Cod-liver 
oil  has  also  been  administered. 

Some  interesting  observations  on  local  or  surface  temperature  were  care- 
fully made  with  the  surface  thermometer  of  Seguin.  They  were  all  taken 
during  the  last  week  in  July,  and  after  the  patient  had  been  under  electrical 
treatment. for  nearly  two  months,  her  hands  and  fingers  feeling  and  looking 
better  than  they  had  for  a  long  time,  and  yet  it  will  be  seen  that  they 
were  generally  quite  low.  For  the  thumbs  and  fingers  in  each  case  the 
temperatures  of  the  tips  or  ends  were  taken.  In  all  the  observations 
except  the  first,  the  axillary  temperature  and  that  of  the  room  were  also 
noted. 

Surface  Temperatures,  July  26,  1878  : — 

Right  thumb,  85.1°  F.    Left  thumb,  86°  F. 

"    index  finger,  86.9°  F. 

"    middle    "  85.1°  F. 

"    ring        "  85.7°  F. 

"    little       "  83.3°  F. 

Palm  of  right  hand,  93.2°  F. 

Back     "        "  89.6°  F. 

No.  CLII  Oct.  1878.  28 


"    index  finger,  84.2°  F. 

"    middle  "  87.8°  F. 

"    ring       "  84.2°  F. 

"    little      "  86°  F. 

Palm  of  left  hand,  93.2°  F. 

Back    "       "  88.7°  F, 


434        Mills,  Vaso-motor  and  Trophic  Affection  of  Fingers.  [Oct. 


This  table  shows  considerable  variation  in  the  temperature  of  the  finger- 
ends,  ranging  between  83.3°  F.  and  87.8°  F.  The  marked  difference 
between  the  temperature  of  the  palmar  and  of  the  dorsal  surface  of  the 
hand  is  worthy  of  notice. 

In  the  observations  which  follow,  I  confined  myself  to  the  thumbs, 
index,  and  middle  fingers  as  being  sufficient  for  all  practical  purposes. 
The  processes  of  localized  faradization,  localized  galvanization,  and  gal- 
vanization of  the  brain  and  sympathetic  have  been  described  when  speak- 
ing of  treatment. 

July  27.  Temperatures  taken  immediately  before  and  immediately  after 
localized  faradization  : — 

Before.         After.  Before.  After. 

Eight  thumb,          87.8°  F.  89.6°  F.  Left  thumb,  87.8°  F.  89. G°  F. 

"    index  finger,  87.8°  F.  89.69  F.     "    index  finger,  87.8°  F.  87.8°  F. 

"    middle  "       87.8°  F.  89.1°  F.     "    middle  "  87.8°  F.  89.3°  F. 

Temperature  in  right  axilla,  101.3°  F. 
"        in  left      "       102°  F. 
11        of  room,  83°  F. 

It  will  be  seen  that  an  average  elevation  of  temperature  of  more  than 
1.3°  F.  was  produced  by  the  farad  ic  applications.  The  electricity  was 
only  applied  for  a  very  short  time,  from  one  to  two  minutes  for  each 
finger,  but  the  current  used  was  as  strong  as  the  patient  eared  to  bear. 
The  high  axillary  temperatures,  which  varied  for  the  two  sides  of  the 
body,  were  somewhat  astonishing.  I  think  that  they  were  due  to  the  con- 
dition of  the  patient's  lungs. 

July  29.  Temperatures  taken  immediately  before  and  immediately 
after  localized  galvanization  : — 

Before.         After.  Before.  After. 

Eight  thumb,           78.8°  F.  79.7° F.  Left  thumb,  80.6°  F.  79.7°  F. 

"    index  finger,  78.8°  F.  79.7°  F.  "    index  finger,  78.8°  F.  77.7°  F. 

"    middle  "       79.7°  F.  79.8°  F.  "    middle  ^  78.8°  F.  83.3°  F. 

Temperature  in  right  axilla,  101.2°  F. 

in  left      "       101. G°F. 
"        of  room,  81°  F. 

For  four  of  the  fingers  and  the  right  thumb  in  this  observation,  localized 
galvanization  caused  an  average  rise  of  about  1.6°  F.,  but  for  the  left 
thumb  and  index  finger  an  average  fall  of  1°  F.  took  place.  How  much 
this  unexpected  depression  of  temperature  was  due  to  some  accidental 
circumstance,  such  as  a  current  of  air  or  some  emotional  disturbance,  I  am 
not  prepared  to  say;  but  apparently  she  was  under  the  same  conditions 
throughout.  The  entire  average  elevation  was  about  .6°  F.  In  the  case 
of  the  left  middle  finger,  however,  4.5°  F.  were  gained.  High  axillary 
temperatures,  differing  for  the  two  sides,  were  again  observed.  Her 
fingers  and  thumbs  were  bluer  and  felt  colder  than  at  any  of  the  other 
thermometric  observations. 

July  30.  Temperatures  taken  immediately  before  and  immediately 
after  galvanization  of  the  brain  and  cervical  sympathetic  (so  called) : — 

Before.  After.  Before.  After. 

Eight  thumb,          87.8°  F.  85.1°  F.  Left  thumb,  91.4°  F.  88. 7°  F. 

"    index  finger,  87.8°  F.  87.8°  F.      "    index  finger,  84.2°  F.  86.9°  F. 

"    middle  "      86°  F.  84.2°  F.      "    middle    "  88.7°  F.  89.6°  F. 

Temperature  in  right  axilla,  101°  F. 
"  in  left  "  101°  F. 
"         of  room,  79°  F. 


1878.]    Mills,  Vaso-motor  and  Trophic  Affection  of  Fingers.  435 

A  depression  of  temperature  occurred  for  both  thumbs  and  two  of  the 
fingers,  and  an  elevation  for  the  other  two  fingers.  On  the  whole,  we 
have  an  average  loss  of  .6°  F.  A  careful  repetition  of  this  observation 
showed  a  more  marked  lowering  of  temperature.  The  general  tempera- 
ture was  still  high. 

As  in  surface  thermometry  we  have  no  absolute  "  norme"  or  standard, 
I  thought  it  advisable  to  make  an  observation  on  the  temperatures  of  my 
own  fingers,  in  order  to  establish  a  relative  norme. 

Temperatures  taken  on  the  writer : — 

Right  thumb,  93°  F.      Left  thumb,  93.2°  F. 

index  finger,  92°  F.        "    index  finger,  92.3°  F. 

"     middle  "  92.8°  F.      "    middle  "    '  92. 7°  F. 

Temperature  of  room,  83°  F. 

The  therapeutical  inference  to  be  drawn  from  these  experiments  would 
seem  to  be  that  localized  faradization  and  localized  galvanization  are  ad- 
visable plans  of  treatment,  and  that  galvanization  of  the  centres  is  not 
to  be  recommended,  apparently  causing  a  lowering  of  the  temperature  of 
the  extremities. 

I  present  this  case  for  its  own  sake,  believing  it  to  possess  sufficient 
interest  and  peculiarity  to  call  for  its  publication.  The  literature  of  the 
subject  is  scant.  A  few  somewhat  similar  cases  have  been  reported,  but 
none  altogether  analogous,  as  far  as  I  have  been  able  to  discover.  The 
small  abscesses  which  formed  in  this  case  at  the  finger-tips  were  a  striking 
peculiarity.  In  the  report  of  the  Proceedings  of  the  New  York  Neurolo- 
gical Society,  at  their  stated  meeting  held  April  1,  1878,  and  published  in 
the  Medical  Record  for  May  11,  1878,  mention  is  made  of  a  paper  read 
by  Dr.  Thomas  A.  McBride,  and  entitled  "  Digiti  Mortui  or  Dead  Fingers." 
In  this  article  a  case  similar  in  many  respects  to  that  just  given  is  re- 
ported : — 

In  a  man,  aged  thirty-two,  of  neurotic  constitution,  certain  parts  of  the  index 
and  middle  fingers  of  both  hands,  and  also  of  the  end  of  the  ring  finger  of  the 
right  hand,  at  irregular  intervals  and  for  varying  periods,  became  cold,  numb,  and 
stiff,  and  of  a  dead- white  paleness.  Some  loss  of  sensibility  was  present  in  the 
affected  parts,  which  were  moderately  painful.  These  symptoms  were  replaced 
at  times  by  a  dusky,  often  purplish-red  colour  of  the  same  parts,  and  this  was- 
accompanied  by  the  sensation  of  having  been  stung  by  nettles.  Fatigue,  exposure,, 
cold,  emotion,  and  similar  causes  brought  on  the  attacks.  The  patient  was  phthi- 
sical, but  had  not  had  active  symptoms  for  four  years.  He  had  also  suffered  for 
two  months  in  1874  from  subacute  spinal  paralysis,  but  had  entirely  recovered. 
He  was  addicted  to  the  use  of  alcohol  and  to  sexual  excesses,  but  had  never  had 
syphilis. 

Dr.  McBride  gives  the  following  brief  resume  of  the  literature  bearing 
on  the  subject :  The  disease  was  first  described  by  Brodie  in  his  "  Lectures 
on  Local  Nervous  Disorders,"  published  in  1837,  but  delivered  earlier  ;  re- 
ferred to  by  Huston  in  1836  ;  by  Raymond  in  1862,  1872,  and  1874;  by 
Nothnagel  in  1866  ;  by  Estlander  in  1870  ;  by  Fischer  in  1875  ;  and  by 
Allan  McLane  Hamilton  in  the  New  York  Medical  Journal  for  October  r 
1874. 


436        Mills,  Vaso-motor  and  Trophic  Affection  of  Fingers.  [Oct. 


Dr.  Hamilton's  article  is  entitled  "  Chronic  Vaso-motor  Hyper-irrita- 
tion." He  alludes  to  an  affection,  consisting  of  temporary  spasm  of  the 
muscular  coats  of  the  small  vessels  of  some  limited  spot,  the  site  being 
usually  a  part  of  the  hand. 

Zunker  reported  "Two  Cases  of  Vaso-motor  Neurosis,"  in  Berliner 
Klinische  Wochenschrift,  for  August  21  and  28,  1876;  and  Dr.  Mader 
(  Wien  Med.  Presse,  June  9  and  16,  1878)  has  placed  on  record  "Two  Re- 
markable Cases  of  Angio-neurosis."  These  cases  were  not  particularly 
affections  of  the  extremities. 

Dr.  S.  Weir  Mitchell,  in  the  last  number  of  the  American  Journal,  in 
a  valuable  paper  on  a  "Rare  Vaso-motor  Neurosis  of  the  Extremities," 
reports  a  series  of  cases  some  of  which  are  similar  in  some  respects  to  the 
case  now  presented.  The  case  reported  by  Dr.  Henry  L.  Stille,  of  Guer- 
rero, Mexico,  and  placed  at  Dr.  Mitchell's  disposal  by  Professor  Alfred 
Stille,  was,  on  the  whole,  perhaps  most  like  my  own. 

A  careful  examination  of  the  cases  mentioned  in  these  articles,  however, 
will  show  various  points  of  dissimilarity,  such,  for  instance,  as  the  absence 
of  abscesses,  duration,  differences  in  the  state  of  sensibility,  effects  of  use 
and  of  heat  and  cold,  results  produced  by  change  of  position,  etc. 

At  present  I  prefer  not  to  theorize  in  regard  to  the  cause  of  the  peculiar 
condition  presented  by  this  case.  Dr.  McBride  regarded  the  condition 
exhibited  in  his  case  as  produced  reflexly  through  the  vaso-motor  system ; 
and  believed  that  it  indicated  a  nervous  system  of  great  mobility,  but  other- 
wise had  no  significance.  Dr.  Hamilton  speaks  of  the  affection  to  which  he 
alludes  as  due  to  a  hyper-irritation  of  local  sympathetic  vaso-motor  fila- 
ments. Dr.  Mitchell,  in  referring  to  his  cases,  says  that  they  probably 
represent  an  unrecognized  type  of  spinal  or  cerebro-spinal  disorders,  and 
that  they  may  be  found  in  the  future  to  be  associated  with  distinct  lesions 
of  definite  regions. 

In  looking  for  an  explanation  of  the  phenomena  presented  by  my  case, 
the  existence  of  mitral  stenosis  will,  of  course,  at  once  attract  attention. 
It  is  well  known  that  in  venous  obstruction  from  cardiac  disease,  or  other 
cause,  blueness  and  coldness  of  the  finger-ends,  and  other  parts  of  the  body, 
may  be  produced.  Some  of  her  symptoms  were,  no  doubt,  due  to  or  were 
aggravated  by  her  heart  disorder,  and  also  by  the  state  of  her  lungs ;  but 
the  marked  trophic  disturbances,  resulting  in  the  formation  of  abscesses, 
and  the  absence  of  any  affection  of  the  feet,  among  other  reasons,  would 
indicate  that  something  more  was  necessary  to  a  full  explanation  of  the 
case  than  the  cardiac  or  pulmonary  disease.  The  coexistence  of  phthisis, 
and  valvular  disease  or  the  heart,  with  vaso-motor  and  trophic  disturbances 
in  other  parts,  naturally  calls  to  mind,  in  a  study  of  causation,  the  sup- 
posed presence  in  the  medulla  oblongata  of  respiratory,  cardiac,  vaso-motor, 
and  trophic  centres. 


1878.] 


Robinson,  Unilateral  Atrophy  of  the  Face. 


437 


Article  XII. 

A  Case  of  Unilateral  Atrophy  of  the  Face,  accompanied  with 
Slight  Paralysis  of  the  Adductors  of  the  Vocal  Cords.  By  Bev- 
erley Robinson.  M.D.,  Lecturer  upon  Clinical  Medicine  at  the  Bellevue 
Hospital  Medical  College.  New  York. 

A.  B.,  aet.  26,  theological  student,  single,  was  born  in  a  neighbouring 
country  parish,  of  which  his  father  was  pastor.  He  came  under  my  care 
ou  April  12th  of  the  present  year  for  weakness  of  voice  following  prolonged 
efforts  of  speech.  Until  the  age  of  fourteen  years  no  trace  of  the  present  dis- 
figurement was  visible.  After  that  age  friends  began  to  ask  my  patient  as 
to  the  cause  of  the  red  and  sometimes  blue  streak  upon  his  forehead,  which 
showed  itself  during  times  of  excitement,  or  when  his  body  was  warmer  or 
colder  than  usual.  Upon  the  first  appearance  of  this  streak  there  was  no 
indentation  at  the  vertex  and  no  irregularity  of  the  upper  lip.  The  hair 
on  the  top  of  the  head  came  out  gradually,  growing  thinner  and  thinner 
over  the  area  which  is  now  bare. 

Patient's  hair  still  falls  out,  though  to  no  great  extent,  around  the  edges 
of  his  bald  spot.  Since  first  noticed  the  streak  upon  the  forehead,  followed 
by  a  notable  depression  of  surface,  has  grown  steadily  more  conspicuous. 
This  development  has  taken  place  very  gradually,  so  that  progressive 
change  is  unobservable  except  when  the  present  condition  is  c-ompared  i*i 
memory  with  what  existed  several  years  ago  (6  to  7).  Since  patient 
has  been  under  my  care  (about  months)  atrophy  of  the  upper  lip  has 
made  slight  progress. 

Actual  state  is  as  follows  :  Patient's  general  health  is  excellent.  One  is 
struck  upon  approaching  him  by  a  notable  depression  over  the  forehead  a 
little  to  the  right  of  the  median  line,  which  extends  from  the  root  of  the 
nose  to  the  hair  covering  the  calvaria,  without  interruption.  Between  the 
frontal  depression  and  the  bald  place  at  vertex  there  is  a  space  about  one 
inch  broad  where  there  are  some  thin  hairs,  but  nevertheless  the  depressed 
appearance  at  their  level,  when  searchingly  examined,  is  found  continuous 
with  bare  area  at  vertex,  and  depression  over  frontal  bone.  The  bare 
place  at  vertex  measures  four  inches  in  an  antero-posterior  direction,  two 
inches  in  its  lateral  diameter.  The  depression  upon  the  forehead  is  two- 
eighths  of  an  inch  broad  at  its  lower  extremity  between  the  eyebrows,  and 
half  an  inch  broad  where  it  reaches  the  border  of  the  hair  of  the  head. 

Besides  the  depression  of  forehead  and  vertex  there  is  considerable 
puckering  of  the  upper  lip  for  one  and  a  half  inch  from  right  labial  com- 
missure towards  the  median  line.  The  lower  lip  on  the  right  side  shows 
also  slight  puckering.  The  parts  affected  are  slightly  more  sensitive  to 
touch  than  is  normal.  This  is  especially  true  of  the  bare  spot  at  the  vertex. 
At  this  level,  as  well  as  throughout  the  extent  of  the  frontal  depression, 
the  skin  is  easily  movable  over  the  bones  beneath.  It  is  thinner  than  the 
skin  of  the  adjacent  region,  and  presents  a  scarred  coloration  (bluish-white). 
The  muscular  fibres  over  the  inner  portion  of  the  right  eyebrow  are  appa- 
rently atrophied.  Frontal  and  parietal  bones  are  both  depressed,  and  have 
evidently  lost  substance.  The  portion  of  the  upper  lip  affected  is  thinner 
than  its  opposite  extremity,  and  permanently  drawn  up  in  such  a  way  as 
to  appear  as  if  there  were  a  loss  of  substance  at  this  level.  The  right  upper 
lateral  incisor  tooth  is  always  visible.   If  the  patient  attempts  to  close  his 


488 


Robinson,  Unilateral  Atrophy  of  the  Face.  [Oct. 


mouth  the  right  labial  commissure  is  notably  drawn  upwards  and  towards 
the  right.  In  conversation  there  is  always  quite  a  gap  between  the  two 
lips  on  the  right  side.  The  lower  lip  on  the  right  side  is  not  quite  as  thick 
as  on  the  left.  The  affected  portions  of  both  lips  contract  well  under  the 
influence  of  a  mild  faradic  current,  and  there  is  evident  pain  upon  pricking 
with  a  pin. 

Palate  and  uvula  show  no  deviation  from  median  line.  Taste,  smell, 
hearing,  and  eyesight  are  all  perfect.  Patient  has  never  BufFered  any 
pains  locally — either  in  lips,  forehead,  or  vertex.  His  present  throat- 
trouble  dates  from  about  eighteen  months  ago.  It  consists  mainly  of 
weakness  and  hoarseness  in  singing,  and  at  times  he  has  falsetto  notes  in 
ordinary  conversation.  He  attributes  throat-trouble  to  undue  exertion 
(singing,  shouting,  cheering,  etc.)  under  unfavourable  ambient  conditions 
of  night  air  and  smoky  rooms,  during  his  collegiate  course.  Upon  laryn- 
goscopy examination  slight  paralysis  of  the  adductor  muscles  of  the  vocal 
cords  is  apparent.  There  is,  however,  no  congestion  and  no  other  morbid 
condition.    Pharynx  and  faucial  opening  are  healthy. 


June  27,  1878  I  have  continued  to  treat  patient  until  present  date, 

partly  by  means  of  the  faradic  current  applied  externally  to  the  muscles  of 
the  throat,  partly  by  astringent  solutions  carried  directly  in  contact  with  the 
vocal  cords.  He  has  also  taken  a  tonic  internally  composed  of  iron,  phos- 
phoric acid,  and  strychnia.  His  voice  is  to-day  much  stronger  than  it  was 
when  treatment  was  first  begun,  although  not  yet  completely  restored.  The 
unilateral  atrophy,  in  so  far  as  the  upper  lip  is  concerned,  has  made  slight 
progress. 

Remarks  My  excuse  for  publishing  the  above  case  is  the  relative 

rarity  of  the  affection  of  which  it  furnishes  an  interesting  example.  Only 


1878.]  Biddle,  Experiments  on  Lead  Carbonate.  439 

four  analogous  eases  have  been  brought  before  professional  notice  in  the 
United  States.  One  by  Hammond,  another  by  Draper,  a  third  by  Ban- 
nister, and  this  fourth,  by  myself.  I  should  have  been  glad  to  make  an 
examination  of  the  muscular  fibres  of  the  upper  lip  and  state  their  con- 
dition. This  my  patient  would  not  permit.  I  presume  there  is  atrophy 
in  my  case,  but  not  muscular  degeneration,  on  account  of  the  preservation 
of  contractility.  The  circumstance  of  the  laryngeal  paralysis  is  note- 
worthy, but  from  the  fact  of  its  improvement  under  treatment  I  can 
scarcely  believe  there  is  any  relation  between  the  two  affections  considered 
other  than  that  of  coincidence.  The  nerve  connection  of  the  facial  in  its 
course,  with  the  pneumogastric,  cannot,  moreover,  explain  any  propaga- 
tion of  diseased  structure  from  the  periphery  towards  the  nervous  centres. 
And  the  only  probable  solution  of  the  problem  is  that  the  disease  is  situ- 
ated, in  this  instance,  in  the  bulb,  and  is  an  affection  of  the  trophic  cells 
which  are  the  nucleus  of  the  right  facial  nerve. 

Note. — The  patient,  whose  history  is  recorded  above,  was  presented  by 
me  at  a  stated  meeting  of  the  New  York  Neurological  Society,  June  2, 
1878. 


Article  XIII. 

Some  Expepjments  on  the  alleged  Poisonous  Action  oe  Lead  Car- 
bonate in  freshly  paixted  Rooms.  By  Clement  Biddle,  M.D.,  As- 
sistant Surgeon,  U.  S.  Navy.1 

These  experiments  were  made  with  the  view  of  investigating  the 
alleged  poisonous  action  of  the  lead  carbonate  of  white  paint  from  freshly 
painted  rooms;  that  is,  to  find  out  whether  the  cases  of  so-called  lead 
poisoning  resulting  from  the  occupation  of  freshly  painted  chambers  were 
really  due  to  the  lead  of  the  paint  or  not.  I  had  always  believed  that  lead 
poisoning  from  this  sort  of  exposure  was  tolerably  certain  to  follow,  until 
the  sudden  illness  of  a  friend,  supposed  to  be  from  this  cause,  turned  out 
to  be  nothing  more  alarming  than  a  bilious  attack,  when  the  subject  sug- 
gested itself  to  my  mind  as  a  proper  one  for  investigation.  Can,  then,  a 
healthy  person  be  poisoned  from  breathing  the  air  of  a  freshly  painted 
room  ?  is  now  the  question  for  solution. 

The  possibility  of  such  is  held  to  be  probable  by  all  authorities.  Dr. 
Taylor,  in  his  work  on  Poisons,  alludes  to  himself  as  having  suffered  from 
severe  colic  through  respiring  the  vapour  of  fresh  paint.    Prof.  Austin 

1  An  abstract  of  the  Thesis  awarded  the  Chemical  Prize,  at  the  Commencement  of 
the  Jefferson  Medical  College,  March,  1878. 


440 


Biddle,  Experiments  on  Lead  Carbonate. 


[Oct. 


Flint,  Sr.,  in  his  Practice  of  Medicine,  says,1  "lead  poisoning  Las  repeatedly 
occurred  from  sleeping  in  newly  painted  rooms."  Trousseau,  in  his  work, 
speaks  of  the  same  fact.  Here,  indeed,  is  high  authority;  and,  moreover, 
Dr.  Reese,  in  his  Toxicology,  considers  the  effect  to  be  due  to  volatile 
emanations  impregnated  with  lead  carbonate,  the  volatile  emanations  being 
presumably  due  to  oil  of  turpentine,  as  white  lead2  paint  is  a  mixture  of 
lead  carbonate  (PbC03)  and  hydrate  (Pb2HO)  in  the  oils  of  turpentine 
and  linseed. 

Notwithstanding  the  above,  I  have  been  unable  to  detect  the  slightest 
trace,  after  a  series  of  very  careful  experiments,  of  lead,  conducted  under 
two  different  plans  upon  a  diminutive  room  (a  box)  whose  inner  walls 
were  coated  with  fresh  white  paint,  the  tests  seeking  to  find  minute  par- 
ticles of  lead  in  the  air  of  the  chamber. 

The  introduction  of  lead  into  the  system,  through  volatile  emanations, 
in  sufficient  quantity  to  give  rise  to  morbid  effects,  may  take  place  by 
means  of  the  skin  or  the  lungs.  This  is  the  rationale  of  the  lead  cachexia 
from  the  point  undergoing  discussion.  If,  however,  it  can  be  shown  by 
experiments  in  which  water  is  proved  to  have  absorbed  no  lead,  alter  ex- 
posure to  the  emanations  of  white  paint,  by  the  most  delicate  tests,  and 
also  that  none  can  be  found  in  the  neighbouring  atmosphere  under  similar 
circumstances,  must  the  inference  not  be  that  lead  poisoning  cannot  result 
from  the  occupation  of  freshly  painted  rooms? 

My  experiments  will  endeavour  to  demonstrate  the  above  statement. 

The  apparatus  employed  was  of  simple  nature,  consisting  of  an  oblong 
box,  eighteen  inches  long,  ten  inches  wide  and  deep,  so  arranged  that 
sheets  of  paper  coated  with  white  paint  could  be  inserted  within  the  box 
on  all  sides,  except  the  floor,  upon  which  was  placed  a  shallow  dish  of 
distilled  water.  In  explanation  let  me  say,  that  by  exposing  in  such  an 
apparatus  a  dish  of  water,  any  particles  of  matter  given  off  from  the  sheets 
(provided  that  they  were  heavier  than  air)  would  be  apt  to  be  taken  up 
by  the  water,  and  readily  detected.  To  make  the  work  more  thorough 
the  sheets  were  coated  with  the  different  constituents  of  white  paint,  and 
the  exposed  water  tested  separately;  that  is,  an  experiment  was  made  with 
oil  of  turpentine,  and  one  with- linseed  oil.  This  was  done  to  arrive  at 
some  conclusion  as  to  the  volatile  action  of  these  substances  upon  the  lead 
carbonate  of  the  white  paint. 

The  details  of  these  different  trials  are  too  lengthy  to  be  given  in  full, 
but  suffice  it  to  say,  that  in  each  experiment  not  only  were  the  substances 
applied  to  the  sheets  found  to  have  been  absorbed  by  the  exposed  water, 
but  also  that  these  substances  experimented  Avith  might  be  a  means  of 
communication  or  of  spreading  the  lead  carbonate  of  the  white  paint.  In 

1  Flint's  Practice,  4th  ed.,  p.  478. 

-  Attfield's  Chemistry,  5th  ed.,  p.  185. 


1878.] 


Biddle,  Experiments  on  Lead  Carbonate. 


441 


other  words,  the  oil  of  turpentine  and  the  oil  of  linseed  when  quitting  the 
paint  might  carry  off  small  particles  of  lead.  These  preliminary  trials 
were  then  of  some  value. 

An  experiment  was  next  made  in  which  sheets  of  paper  were  saturated 
with  white  paint,  and  inserted  within  the  experimenting  box.  Upon  the 
floor  of  the  latter  was  placed  a  shallow  dish  of  distilled  water.  This  water 
had  been  previously  tested  with  sulphuretted  hydrogen  (H2S)  to  make 
sure  of  the  absence  of  lead.  The  sheets  were  thus  exposed  to  the  water 
for  three  days.*  Upon  removal  the  water  looked  clear,  with  perhaps  a 
slight  oily  appearance.  It  was  acidulated  with  a  drop  of  nitric  acid  (HNOs), 
and  the  sulphuretted  hydrogen  (H2S)  applied,  but  no  trace  of  lead  could 
be  found. 

I  have  performed  the  above  experiment  in  another  way,  that  is,  by 
using  paint  unmixed  with  oil  of  turpentine.  The  results  in  each  case 
were  just  the  same  ;  a  test  of  the  exposed  water  showing  an  entire  absence 
of  lead.  As  has  been  stated  earlier  in  this  article,  volatile  emanations 
were  supposed  by  some  to  be  the  agent  by  which  lead  was  carried  off  from 
paint,  but  the  facts  that  I  have  obtained  from  my  investigations  are 
directly  opposed  to  this  theory. 

As  regards  the  delicacy  of  the  H2S  test  for  lead,  the  following  experi- 
ments were  made.  It  has  been  shown  by  some  chemists  that  this  reagent 
will  show  a  distinct  brownish  tint  even  from  the  most  minute  solutions. 
Thus,  Pfaff1  placed  the  limit  of  the  brown  coloration  in  the  form  of  a 
nitrate  at  1  part  in  100,000  parts  of  liquid;  Lassaigne  at  200,000;  and 
Harting  at  360,000. 

Several  tests  were  made  (five  in  all) ;  the  first  with  50  c.  c.  of  water, 
and  one  milligramme  of  lead  acetate,  and  the  amount  of  water  gradually 
increased  to  1000  milligrammes.  The  details  of  the  last  trial  are  as  fol- 
lows : — 

Distilled  water,  1000  cubic  centimetres, 

Nitric  acid  (HN03),  1  drop, 

Lead  acetate  (Pb2C2H302),       1  milligramme. 

Through  this  weak  solution  H2S  was  passed ;  at  first  there  was  no 
change,  but  by  keeping  up  a  continuous  flow  of  the  gas  the  solution  gradu- 
ally turned  a  very  pale  brown,  better  seen  when  compared  alongside  a 
test-tube  of  distilled  water.  The  delicacy  of  this  test  will  be  better  under- 
stood on  reference  to  the  following  explanation. 

1  c.  c.  distilled  water  =  1000  milligrammes  by  weight. 
1  milligramme  =  ToV otn  0I>  a  gramme. 

Amount  of  water  used  1000  c.  c.  )       ■,        .  i  ,  ,  i 

r  —  Dv  weight  to  a  x,o  o  Wo  otn 
Amount  of  lead  acetate  used  1  milligramme ) 

solution ;  that  is,  1  milligramme  of  lead  acetate  dissolved  in  water,  1000 


1  Micro-Chemistry  of  Poisons,  Wormley,  p.  362. 


442 


Biddle,  Experiments  on  Lead  Carbonate. 


[Oct. 


c.  c.  represents  the  one-millionth  part  by  weight  of  lead  acetate  in  such 
solution. 

This  extreme  limit  of  reaction  is  strong  proof  that  had  lead  carbonate 
from  the  white  paint  of  our  experiments  been  present  in  the  exposed  water 
it  must  have  been  most  minute  in  quantity  to  escape  detection,  and  if 
there,  indeed,  its  infinitesimal  character  could  hardly  be  credited  with 
lead  poisoning. 

This  completes  the  examination  of  water  exposed  to  the  emanations  of 
white  paint.  Mention  has  already  been  made  in  regard  to  the  investiga- 
tion of  the  condition  of  an  exposed  volume  of  air  under  similar  circum- 
stances.   This  was  accomplished  in  the  following  manner : — 

An  air-tight  box  was  obtained  eighteen  inches  long,  ten  inches  wide, 
and  ten  inches  deep,  having  two  openings,  one  at  either  end.  To  one 
was  inserted  the  nozzle  of  a  bellows,  to  the  other  a  bit  of  glass  tube  with 
an  elbow,  the  latter  terminating  in  a  dish  of  distilled  water. 

The  principle  of  the  apparatus  is  as  follows  :  Sheets  of  paper  coated  with 
white  paint  were  to  be  fastened  to  the  inner  Avails  of  the  box,  and  the 
contained  and  exposed  air  was  to  be  forced  through  the  chamber  by  means 
of  the  bellows,  the  glass  pipe  at  the  other  end  conducting  it  (the  air)  to 
the  dish  of  water.  This  procedure  would  carry  away  all  volatile  emana- 
tions, and  bring  them  in  contact  with  the  water.  Into  the  latter  the  de- 
livery tube  of  a  sulphuretted  hydrogen  generator  is  to  be  inserted. 

From  this  description  it  will  at  once  be  seen  that  if  the  exposed  air 
absorbs  lead  from  the  coated  sheets  of  the  box,  it  (the  lead)  must  react  on 
passing  through  the  disli  of  water  with  the  H„S  therein  dissolved. 

Sheets  of  paper  saturated  with  white  paint  were  placed  within  the  ex- 
perimenting chamber,  and  twenty-four  hours  allowed  to  elapse.  The  ap- 
paratus then  underwent  inspection.  A  powerful  contraction  of  the  bellows 
caused  the  inclosed  air  to  make  its  exit  through  the  gla=s  tube,  and  to  pass 
into  the  dish  of  acidified  distilled  water.  An  examination  of  the  latter 
showed  that  no  lead  sulphide  was  present.  The  oil  of  turpentine  had  had 
no  apparent  effect  on  the  lead  of  the  paint.  But  it  had  acted  on  the  lin- 
seed oil.  By  its  volatility  minute  oil-globules  were  suspended  in  the  air 
of  the  chamber.  This  must  have  been  the  case,  as  the  application  of  the 
bellows  caused  these  globules  to  appear  in  the  dish  of  water. 

These  globules  when  leaving  the  paint  might  have  taken  with  them 
minute  particles  of  lead  carbonate,  completely  enveloping  them  as  it  were, 
and  thus  have  checked  the  reaction  with  the  H.,S  gas.  To  determine  this 
they  were  examined  as  follows  :  Under  the  microscope  they  presented  the 
shape  of  circular  notched  disks  whose  diameter,  measured  with  the  micro- 
meter, was  ^Lth  of  an  inch. 

Chemical  investigation  was  conducted  by  placing  the  globules  in  a  por- 
celain crucible  with  distilled  water,  and  applying  heat  to  destroy  organic 
matter ;  this  process  yielded  small  black  specks,  to  which  were  added  four 


1878.] 


Michel,  Radical  Cure  of  Inguinal  Hernia. 


443 


drops  of  nitric  acid,  and  heat  again  applied,  together  with  the  acid  com- 
pletely destroying  all  organic  matter,  and  converting  any  lead  present  into 
the  soluble  nitrate.  The  residue  was  redissolved  in  a  few  drops  of  distilled 
water,  and  brought  in  contact  with  H2S,  yielding  no  precipitate  or  dis- 
coloration. 

Let  me  add,  in  conclusion,  that  an  experiment  was  made  with  white 
paint  in  which  benzine  was  substituted  for  oil  of  turpentine.  Now  benzine 
is  far  more  volatile  than  oil  of  turpentine,  and  if  the  mode  of  poisoning 
from  lead  under  discussion  be  really  due  to  volatile  emanations,  benzine 
of  all  substances  ought  to  prove  this  to  be  true,  but  it  yielded  entirely 
negative  results ;  in  fact,  evincing  no  more  volatile  action  upon  the  lead 
of  the  paint  than  did  oil  of  turpentine. 


Article  XIV. 

Spanish  Method  of  Using  the  Testicle  in  the  Radical  Cure  or  In- 
guinal Hernia.  By  Middleton  Michel,  M.D.,  Professor  of  Physiology 
and  Histology  in  the  Medical  College  of  the  State  of  South  Carolina,  Charleston. 

These  comments  upon  the  use  of  the  testicle  in  the  cure  of  inguinal 
hernia  suggest  themselves  upon  the  perusal  of  a  rare  and  curious  case  re- 
cently published  in  this  Journal  by  Dr.  Charles  T.  Hunter  (number  for 
January,  1878,  p.  152). 

The  patient  had  for  a  year  been  in  the  habit  of  keeping  his  hernia 
reduced  by  pressing  the  testicle  into  the  inguinal  opening,  until  the  organ 
becoming  finally  fixed  in  this  position,  plugged  up  the  external  opening, 
retained  the  hernia,  and  apparently  cured  the  rupture.  The  writer  re- 
marks that  among  the  many  surgical  expedients  for  a  radical  cure  of  hernia 
"the  human  testicle,  so  far  as  I  have  been  able  to  learn,  has  never  been 
utilized." 

In  a  series  of  papers,  thrown  together  in  the  form  of  chapters,  for  a 
proposed  history  of  the  radical  cure  of  inguinal  hernia,  which  I  recently 
published  in  the  Charleston  Medical  Journal  and  Revieiv,  April,  1876, 
p.  10,  will  be  found  an  account  of  an  ancient  Spanish  method  but  little 
known  to  surgeons,  I  expect,  since  we  find  rarely  any  mention  of  it,  and 
since  it  has  obviously  escaped  the  research  of  Dr.  Hunter.  This  method 
I  have  referred  to  in  the  following  manner  in  the  above-mentioned  pub- 
lication : — 

"  connected  with  this  process  is  a  Spanish  method  so 

perfectly  remarkable,  and  so  closely  resembling  in  principle  the  ensheathing 
of  an  organic  plug,  as  executed  by  Gerdy,  that  we  cannot  omit  mentioning 
it.    The  account  of  this  singular  operation,  the  design  of  which  was  to 


444 


Michel,  Radical  Cure  of  Inguinal  Hernia. 


[Oct. 


obviate  the  necessity  of  castrating  the  patient,  may  be  found  in  a  work 
published  in  1CG5  by  Henry  Moinichen,  physician  to  the  King  of  Denmark 
(Obs.  Med.  Chir.,  Hafmice).  This  writer  says  that  the  Spanish  surgeons 
were  in  the  habit  of  making  an  incision  along  the  course  of  the  spermatic 
cord,  laying  open  the  sac,  and  after  the  reduction  of  the  intestine  pushing 
up  the  cord  and  testicle  into  the  abdomen,  packing  the  remaining  tissues 
and  cellular  structures  into  the  inguinal  canal,  terminating  the  operation 
with  the  golden  suture,  and  closing  the  wound.  The  supposition  was  that 
the  function  of  the  testicles  was  thus  preserved,  but  it  sometimes  happened 
that  the  operation  was  performed  on  both  sides,  which  lead  to  the  dis- 
covery that  it  had  superinduced  complete  sterility;  it  then  became  a  seri- 
ous question  in  the  Church  whether  marriage  should  be  interdicted,  and  a 
message  was  actually  sent  to  Rome,  we  are  told,  to  ascertain  if  it  were  the 
pleasure  of  the  Holy  See  that  those  should  enter  into  the  marriage  state 
who  were  thus  rendered  impotent.  Scultet  in  his  appreciation  of  this  method 
condemns  it  as  not  only  useless,  but  often  dangerous  and  fatal,  from  the 
violent  pressure  and  pain  to  which  the  testicle  must  be  exposed  when 
forced  into  a  narrow  inguinal  canal;  while,  if  the  passage  were  sufficiently 
dilated  to  admit  the  ready  intrusion  of  the  testicle,  the  operation  would  be 
worse  than  useless,  as  the  organ  must  soon  again  descend,  rendering  the 
condition  of  the  individual  most  precarious.  From  his  remarks  upon  this 
subject,  it  would  appear  that  this  surgical  process  was  by  no  means  con- 
fined to  Spain,  but  was  practised  also  in  some  of  the  Austrian  dominions." 

Here  is  a  most  emphatic  use  of  the  testicle  as  an  organic  plug,  securing 
it  in  this  capacity  by  an  actual  operation,  and  yet  even  under  these  circum- 
stances to  no  purpose,  since  the  method  was  abandoned  as  either  inefficient 
when  the  testicle  descended,  or,  being  retained,  underwent  atrophy,  and 
permitted  the  hernia  itself  to  redescend. 

The  obliteration  of  the  external  ring,  if  even  perfectly  accomplished, 
would  not  remedy  the  hernia,  for  the  only  condition  of  a  radical  cure  is 
the  occlusion  of  the  entire  hernial  canal ;  by  the  former  procedure  we  only 
convert  a  complete  into  what  is  known  as  an  interstitial  hernia,  and  as 
Dr.  Hunter  surmises,  there  must  always  remain  the  possibility  of  displace- 
ment of  the  organ  under  a  vis-a-tergo  force  more  or  less  constantly  being 
applied  to  the  testicle.  Should  this  displacement  of  the  testicle,  however, 
never  occur,  an  interstitial  hernia  will  almost  inevitably  reappear  at  some 
future  period,  and  this  will  occur,  as  I  have  seen,  even  where  an  arrest 
of  development  retains  the  testicle  abnormally  within  the  inguinal  canal. 
So  rare  a  case  is  of  sufficient  interest  in  this  connection  to  be  detailed,  and 
I  will  therefore  state,  that  some  years  ago  a  negro  child  was  brought  to  me 
under  the  supposition  that  a  surgical  operation  might  relieve  him.  The 
right  testicle  was  retained  within  the  inguinal  canal  congenitally,  and  the 
right  half  of  the  scrotum  was  not  even  developed;  there  was  no  raphe,  and 
but  one-half  of  a  scrotum  existed  which  contained  its  testicle  on  that  side. 
This  boy  has  grown  to  manhood,  is  married,  and  has  children;  is  a  barber 
by  trade,  resides  near  me  where  I  see  him  daily;  the  testicle  still  remains 
within  the  canal,  for  it  could  not  descend,  as  there  is  no  scrotal  receptacle 


1878.] 


Vance,-  Inversion  of  the  Bladder. 


445 


for  it;  occludes  external  ring  and  two-thirds  of  the  entire  canal;  and 
nevertheless  within  the  last  few  years  a  hernial  protrusion  has  taken  place 
and  distends  the  inguinal  region  most  inconveniently,  and  it  may  he  said 
hopelessly,  since  no  truss  can  he  applied  over  the  part  on  account  of  the 
presence  of  the  testicle ;  nor  should  the  attempt  be  made,  since  experience 
has  taught  that  in  cases  of  this  rare  nature,  among  crytorchides  as  they 
are  called,  if  any  inflammation  arises  in  concealed  testicle,  it  is  most 
readily  extended  to  the  peritoneum,  and  death  from  peritonitis  is  by  no 
means  uncommon. 

While  this  communication  is  particularly  intended  to  call  attention  to 
the  use  which  has  been  made  of  the  testicle  in  the  cure  of  hernia,  yet 
much  more  might  be  said  of  the  interest  connected  with  so  curious  and 
rare  a  case  as  the  one  which  Dr.  Hunter  has  put  upon  record. 


Article  XV. 

Inversion  of  the  Bladder.    By  Reuben  A.  Vance,  M.D.,  of  Gallipolis, 

Ohio. 

Prior  to  the  day  the  following  case  was  brought  to  my  notice  I  had 
never  met  with  an  instance  of  inversion  of  the  bladder.  The  phenomena 
it  presented  were  so  novel  that  I  subsequently  spent  no  little  time  in 
endeavouring  to  find  what  light  medical  literature  could  cast  on  the  subject. 
In  a  review  of  the  second  volume  of  "  Saint  Thomas's  Hospital  Reports," 
in  the  American  Journal  of  the  Medical  Sciences,  brief  mention  was  made 
of  a  paper  describing  the  case  of  a  patient  under  the  care  of  Mr.  John 
Croft,  F.R.C.S.,  who  up  to  that  time  had  been  able  to  find  recorded  only 
three  other  cases.  The  following  are  the  notes  of  my  case,  taken  the  day 
I  examined  the  patient  and  recognized  the  true  nature  of  the  affection : — 

A  resident  of  Jackson  County,  in  this  State,  named  Morgan,  called  at 
my  office  in  Xovember,  1877,  and  told  me  of  a  growth  from  the  external 
organs  of  generation  with  which  his  infant  daughter  was  afflicted,  but  his 
description  was  so  obscure  that  I  could  form  no  idea  of  the  case,  and  felt 
compelled  to  decline  prescribing  until  I  could  see  the  patient.  On  the  7th 
of  December,  1877,  he  returned  with  his  wife  and  the  afflicted  child.  Re- 
minding me  of  his  previous  visit,  he  introduced  his  wife,  and  at  once  pre- 
pared the  child  for  my  examination. 

When  the  external  genital  organs  were  exposed,  a  small  purplish-brown 
tumour,  the  size  of  a  hen's  egg,  was  revealed,  which,  on  closer  examina- 
tion, was  found  to  spring  from  the  upper  and  inner  margin  of  the  vulva, 
and  seemed  to  originate  from  the  external  orifice  of  the  urethra.  Exter- 
nally the  tumour  was  pear-shaped,  and,  when  compressed  between  the 
fingers,  was  elastic  and  resistant.  It  could  be  elevated  without  difficulty, 
thus  exposing  the  lower  part  of  the  ostium  vaginas,  and,  when  lifted  away 


446 


Vance,  Inversion  of  the  Bladder. 


[Oct. 


from  the  body  in  this  manner,  its  pyriform  shape  was  exceedingly  well 
marked.  In  using  a  probe  to  determine  the  relation  of  the  tumour  to  the 
urethra,  the  orifice  of  the  latter  was  found  to  encircle  the  neck  of  the 
former.  That  is,  the  probe  revealed  no  attachment  between  the  neck  of 
the  growth  and  the  walls  of  the  urethra  for  a  distance  of  nearly  two  inches. 
The  probe,  while  free  to  enter  this  far  above,  below,  or  on  either  side  of 
the  tumour,  could  not  be  made  to  pass  further  into  the  bladder.  At  this 
point  in  my  examination  the  child  cried  violently,  and,  at  each  gasp,  the 
tension  and  prominence  of  the  tumour  could  be  fell  to  increase. 

Desisting  temporarily  from  my  exploration,  I  noted  the  following  points 
in  the  history  of  the  case:  The  little  girl  was  then  (December,  1877)  in 
her  twenty-second  month,  and  had  suffered  from  dribbling  of  urine  since 
she  was  a  year  old.  The  constant  flow  of  this  excretion  caused  excoriation 
of  the  lower  part  of  her  body  and  the  inner  aspect  of  her  thighs,  and  neces- 
sitated frequent  change  of  napkins.  Shortly  after  this  symptom  developed 
the  mother  said  she  observed  something  filling  up,  and  projecting  from, 
the  water-passage.  AVatching  the  parts  daily,  she  soon  convinced  herself 
that  the  baby's  incontinence  of  urine  arose  from  something  growing  out  of 
the  urethra,  and  she  consulted  several  physicians  as  to  the  nature  of  the 
growth.  From  the  latter  she  learned  that  polypi  grew  from  such  places, 
and  it  was  with  a  view  of  having  the  polypus  removed  that  her  husband 
originally  came  to  consult  me.  The  mother  also  stated  that  she  had  passed 
a  wire  (a  smooth  knitting-needle)  into  the  urethra  when  exploring  the 
parts,  that  it  invariably  made  the  child  cry,  and  crying  caused  the  tumour 
to  enlarge  and  protrude.  In  October  she  saw  that  a  small  part  of  the 
growth  projected  even  when  the  child  was  quiet ;  and,  shortly  afterwards, 
when  endeavouring  to  trace  the  extent  of  the  growth,  the  child  became  ex- 
cited, screamed  violently,  and  bore  down  with  so  much  force,  that  the 
tumour  suddenly  enlarged  to  its  present  bulk.  At  times  it  subsequently 
diminished  to  the  size  of  an  acorn,  but  it  never  resumed  its  former  small 
dimensions,  and  never  receded  within  the  urethral  canal. 

While  the  mother  was  detailing  these  facts,  the  child  gradually  ceased 
sobbing  and  crying — it  had  screamed  incessantly  from  the  moment  the 
parents  first  started  to  expose  the  diseased  part — and  this,  too,  while  I 
continued  to  manipulate  the  growth  and  adjacent  structures.  As  the  child 
grew  quiet,  the  tension  and  prominence  of  the  tumour  seemed  much  less 
than  before,  and  this  change  in  the  characters  revealed  to  the  sense  of 
touch  was  accompanied  by  a  decided  alteration  in  colour.  From  a  purplish- 
brown  hue,  the  growth  changed  to  a  yellow  tint.  Also,  an  indistinct  feel- 
ing of  fluctuation  attracted  my  attention  to  the  part,  and,  as  I  renewed  my 
examination,  the  child  again  commenced  to  scream  and  cry.  The  tumour 
at  once  grew  tense  and  hard,  and  became  of  a  deep-purple  colour.  What- 
ever trace  of  fluctuation  there  might  have  been  before,  disappeared  with 
the  first  forced  expiration.  Quite  a  quantity  of  fluid  bedewed  the  parts, 
but,  as  I  had  no  other  thought  than  that  it  came  from  the  meatus  urinarius, 
I  neglected  to  search  for  any  other  origin.  Requesting  the  mother — who 
was  supporting  the  child  in  a  semi-erect  position  before  me — to  quiet  her 
babe,  I  explained  to  the  parents  my  idea  of  the  case,  that  the  tumour  was 
a  polypus  developed  from  the  mucous  membrane  of  the  urinary  passages 
at  some  point  near  the  junction  of  the  urethra  and  bladder ;  that  it  was 
the  development  of  the  former  which  caused  the  incontinence  of  urine,  and 
that  the  incontinence  now  present  depended  upon  relaxation  of  the  urethra 
and  contraction  of  the  bladder.  Contraction  of  the  vesical  walls  accounted 


1876.] 


Vance,  Inversion  of  the  Bladder. 


U7 


for  the  fact  that  the  probe  passed  but  two  inches  from  the  meatus — a  con- 
dition which  I  explained  by  the  dependent  position  of  the  tumour,  and  the 
fact  that  it  rendered  the  urethral  canal  patent,  thus  permitting  the  urine  to 
escape  as  soon  as  carried  into  the  bladder.  My  advice  to  the  parents  was 
to  have  the  child  operated  upon,  and  I  explained  the  procedures  necessary 
to  pass  a  ligature  around  the  neck  of  the  growth,  near  its  origin. 

In  order  to  determine  the  attachment  of  the  tumour,  I  had  the  parents 
support  the  child  while  I  examined  the  parts  through  the  rectal  walls. 
Passing  my  right  forefinger  its  full  length  into  the  rectum,  I  carried  its 
pulp  as  near  the  junction  of  bladder  and  urethra  as  I  could — a  method  of 
examination  peculiarly  available  in  children  of  that  age.  Inserting  a  small 
female  catheter  as  far  as  possible  along  the  urethra,  I  placed  a  finger  on 
the  base  of  the  tumour,  and  at  the  same  time  carried  the  point  of  the  finger 
in  the  rectum  towards  the  supra-pubic  region.  Despite  the  fact  that  the 
child  was  screaming  its  loudest,  and  struggling  with  all  its  might,  the 
tumour,  ordinarily  tense  and  resistant  under  such  circumstances,  suddenly 
became  so  soft  and  yielding  that  I  directed  the  father  to  so  move  the 
child's  hips  that  I  could  see  the  growth.  To  my  great  surprise  I  found 
my  finger  had  indented  the  tumour  as  it  would  a  soft  rubber  ball.  Re- 
leasing the  catheter  I  grasped  the  growth  with  my  left  hand,  and,  as  I 
compressed  it,  it  slowly  collapsed,  and  began  to  recede  within  the  urethra, 
and,  as  it  disappeared  externally,  my  finger  in  the  rectum  could  feel  an 
increase  in  the  bulk  of  the  structures  in  the  vesical  region.  At  this  time 
the  child's  hips  were  elevated  above  its  trunk  ;  directing  the  father  to 
lower  still  more  its  head  and  shoulders.  I  elevated  its  hips  as  I  compressed 
the  slowly  diminishing  growth.  Finally,  as  the  last  of  the  tumour  entered 
the  meatus.  I  followed  it  with  a  catheter,  and  found  no  difficulty  in  insert- 
ing the  latter  between  three  and  four  inches.  While  the  child  was  kept 
in  position  with  its  shoulders  depressed  and  hips  elevated,  I  made  a  care- 
ful inspection  of  the  urethra,  and  found  the  canal  greatly  enlarged — enlarged 
to  such  an  extent  that  I  readily  inserted  the  first  phalanx  of  my  little  finger 
into  its  orifice — and  its  tissues  so  relaxed  that  they  scarcely  contracted  on 
my  finger.  Yet  the  tumour  had  disappeared,  and  no  trace  of  it  was  to  be 
found.  With  the  child  before  me,  I  re-examined  the  parts,  and  carefully 
reviewed  every  point  in  the  case. 

My  first  idea,  that  the  tumour  was  a  polypoid  growth  from  near  the 
junction  of  the  vesical  and  urethral  cavities,  was  no  longer  reconcilable 
with  the  facts.  Despite  its  seeming  impossibility,  the  only  tenable  surmise 
was  that  the  bladder  had  been  turned  inside  out.  The  impossibility  of 
inserting  a  catheter  while  the  tumour  protruded,  together  with  the  absence 
of  evidences  of  vesical  distension,  or  even  of  the  presence  of  that  organ  in 
its  proper  position,  and  the  continual  dribbling  of  urine,  contrasted  with 
the  ease  with  which  a  catheter  could  be  inserted  when  the  tumour  was  re- 
duced, the  immediate  development  of  such  tactile  phenomena  as  denoted 
the  return  of  the  bladder  to  its  position,  the  complete  disappearance  of  the 
tumour,  and  the  sudden  cessation  of  urinary  dribbling,  were  arguments 
that  could  be  answered  in  no  other  way  than  by  supposing  the  bladder  to 
have  been  inverted.  I  at  once  explained  my  change  of  opinion  to  the 
parents,  and  inquired  as  to  their  knowledge  of  any  previous  reduction  of 
the  protrusion.  The  mother  was  certain  that  it  had  not  receded  within 
the  meatus  since  October.  When  I  inquired  about  the  child  straining  in 
defecation,  etc.,  I  was  informed  that  they  thought  nothing  of  the  first 
development  of  urinary  incontinence,  for  the  child  had  whooping-cough 


448        P or  Cher,  Ligation  of  the  Common  Carotid  Artery.  [Oct. 


when  eleven  months  old,  and  coughed  with  great  violence.  I  imagine  the 
parents  were  surprised  at  my  change  of  opinion,  but  when  they  learned 
that  no  operation  would  be  required  they  were  not  disposed  to  criticize  the 
suddenness  with  which  my  view  of  their  child's  case  was  modified.  The 
child  was  ordered  five  drops  of  the  tincture  of  nux  vomica  three  times  a 
day,  and  the  parents  were  directed  to  keep  it  constantly  in  a  reclining 
position  with  its  hips  elevated,  to  sponge  the  urethral  orifice  with  cold 
water  twice  a  day,  and  see  that  it  was  placed  in  a  recumbent  posture  when 
its  bowels  were  moved. 

Since  my  little  patient  was  taken  home  I  have  not  seen  her,  but  her 
father  has  called  a  number  of  times.  From  him  I  learn  that  not  only  has 
there  been  no  return  of  the  inversion,  but  the  dribbling  of  urine  has  been 
gradually  growing  less  and  less.  The  clinical  lesson  taught  me  by  my  own 
case  richly  compensated  me  for  its  unpleasant  phases,  and  I  now  record  it, 
trusting  that  it  may  aid  in  diffusing  an  acquaintance  with  the  curious 
phenomenon  of  which  it  is  an  example. 


Article  XVI. 

Ligation  of  the  Common  Carotid  Artery  at  its  Lower  Third — Ani- 
mal Ligature  used  ;  Uxsuccesseul  ;  Autopsy.  By  F.  Peyre  Porcher, 
M.D.,  Associate  Physician  of  City  Hospital,  Charleston  ;  Professor  of  Materia 
Medica  and  Therapeutics,  and  of  Clinical  Medicine,  in  the  Medical  College 
of  the  State  of  South  Carolina. 

We  report  this  case,  though  the  result  was  unfavourable,  that  it  may  be 
recorded  as  such,  and  because  it  may  be  instructive  with  regard  to  the 
selection  of  ligatures  for  securing  the  larger  arteries,  especially  those  near 
the  heart.  It  confirms,  we  think,  the  objections  held  by  others  against 
animal  ligatures  used  under  similar  circumstances. 

Besides  the  usual  difficulty  of  knowing  whether  the  aneurism  did  not 
proceed  directly  from  the  aorta,  the  case  was  regarded  as  a  very  desperate 
one  from  the  beginning.  Though  very  many  years  in  charge  of  large  hos- 
pitals, both  military  and  civil,  we  cannot  pretend  to  any  great  experience  in 
tying  arteries  (the  femoral  twice  and  the  anterior  tibial  once),  yet  we  have 
had  the  benefit  of  much  practice  on  the  cadaver,  whilst  under  the  tuition 
of  M.  Sappey,  in  1854,  at  Clamart,  near  Paris,  and  elsewhere.  We  have, 
therefore,  some  right  to  declare  that  the  artery  in  the  present  instance  was 
extremely  deep  seated,  and  this  added  to  the  practical  difficulties  of  the 
operation ;  besides  the  other  positive  dangers  threatening  life,  which  ex- 
isted in  the  special  condition  of  the  tumour  itself. 

A  coloured  seaman,  set.  38,  a  native  of  Baltimore,  and  in  service  for 
twenty-five  years,  entered  the  marine  department  of  the  City  Hospital 


1878.]     Pokcher,  Ligation  of  the  Common  Carotid  Artery.  449 


June  22d,  1878.  He  was  of  full  habit,  robust  of  frame,  and  remarkably 
muscular ;  but  there  were  several  cicatrices  of  former  scrofulous  abscesses 
upon  the  right  aspect  of  his  neck.  A  large  tumour  also,  with  a  markedly 
scrofulous  look  and  resembling  very  closely  an  immense  abscess,  which 
threatened  momentarily  to  burst  (the  summit  being  whitish,  as  if  contain- 
ing pus),  was  seen  on  the  opposite  side  of  his  neck.  Upon  closer  examina- 
tion it  was  found  to  pulsate  strongly,  with  a  decided  thrill  which  lifted  up 
the  fingers  placed  upon  it — the  characteristic  bruit  of  an  aneurism  being 
also  heard  upon  applying  the  ear.  The  tumour  included  almost  the  entire 
left  side  of  the  neck,  and  rested  upon  the  clavicle — the  neck  being  very 
full,  and  the  muscles  enlarged  and  swollen. 

He  stated  that  it  had  not  commenced  to  become  prominent  till  twenty 
days  previously,  and  he  was  convinced  that  it  was  like  the  other  abscesses 
on  the  opposite  side,  to  which  also  he  had  applied  soap  and  sugar,  and 
they  had  discharged  pus.  Iodide  of  potash,  grs.  xx,  was  prescribed  three 
times  a  day,  and  to  maintain  the  recumbent  position  in  bed.  He  would 
not  consent  to  any  surgical  interference,  though  advised  of  the  imminent 
risk  of  delay.  • 

June  26th.  A  small  and  apparently  superficial  ulceration  burst,  and  a 
thin,  red  fluid  oozed  continually.  The  dose  of  iodide  of  potash  was  in- 
creased to  xxx  grains,  three  times  a-  day. 

27th.  The  oozing  continued,  and  the  patient  having  consented  to  an 
operation,  as  the  only  hope — though  an  exceedingly  slim  one — for  life,  we 
proceeded,  under  the  advice  and  assistance  of  the  consulting  surgeon,  Dr. 
R.  A.  Kinloch,  to  cut  down  upon  and  ligate  the  artery.  There  were  also 
present  our  colleague,  Dr.  J.  S.  Buist,  and  Drs.  F.  L.  Parker,  T.  G.  and 
M.  Simons,  J.  Forrest,  P.  G.  DeSaussure,  and  the  house  physicians. 
Chloroform  being  administered,  a  semicircular  incision,  about  five  inches 
in  length,  was  made,  commencing  near  the  lower  extremity  of  the  thyroid 
gland,  and  passing  parallel  with  the  trachea  and  then  with  the  sternal 
third  of  the  clavicle.  The  clavicular  attachments  of  the  sterno-mastoid 
were  divided  almost  throughout  their  extent,  and  after  careful  dissection 
and  some  difficulty,  on  account  of  the  great  muscularity  of  the  subject,  the 
artery  was  found  deeply  placed  three  and  a  half  inches  below  the  surface 
of  the  wound.  The  vessel  being  lifted  by  the  fingers,  a  catgut  ligature, 
previously  soaked  in  carbolized  oil,  was  passed  under  it  on  an  aneurism 
needle.  The  ligature  was  turned  under  twice  before  the  knot  was  com- 
pleted, and  it  was  drawn  tightly  and  firmly  tied,  the  ends  being  cut 
close  to  the  artery.  No  other  vessel  required  tying ;  there  was  conse- 
quently very  little  bleeding,  the  wound  being  almost  dry  when  the  opera- 
tion was  completed.  It  was  mopped  out  with  carbolized  water,  and  a 
narrow  strip  of  lint,  soaked  in  carbolized  oil,  was  inserted,  and  left  hang- 
ing from  its  lowest  end,  to  promote  drainage,  which  was  not  replaced. 
Interrupted  silver  wire  was  used  to  close  the  external  wound,  and  ten 
minims  of  morphia  given  hypodermically.  All  pulsations  ceased  in  the 
tumour  after  the  artery  was  secured  ;  but  this  slowly  returned  after  some 
minutes,  and  continued  to  be  felt  for  a  few  days,  and  rather  increasing 
before  his  death. 

It  is  needless  to  give  the  details  of  the  treatment  or  the  daily  history  of 
the  pulse,  temperature,  etc.  Suffice  it  to  say,  that  warm  carbolized  water 
was  injected  into  the  wound,  and  the  pulse  having  reached  120  and  the 
temperature  103^°,  veratrum  viride  was  used,  with  occasional  doses  of 
opium,  till  the  one  descended  to  54,  and  the  other  became  normal.  The 
No.  CLII  Oct.  1878.  29 


450        Porcher,  Ligation  of  the  Common  Carotid  Artery.  [Oct. 


tumour  diminished  in  size  sensibly,  and  the  patient's  condition  was  good, 
till  the  morning  of  July  4th,  when  a  violent  hemorrhage  occurred ;  and 
before  the  house  physician,  Mr.  Rhett  (who  had  been  most  carefully  watch- 
ing the  case  from  the  beginning,  and  who  was  resting  within  a  few  feet  of 
him)  could  give  his  assistance,  several  pints  and  quarts  even  of  blood  were 
lost,  and  the  man  was  dead.  Had  time  allowed  in  this  emergency,  it  was 
proposed  to  open  the  tumour,  remove  the  clots,  stanch  the  blood,  and 
secure  the  artery  above. 

Autopsy — A  careful  dissection  was  made  three  hours  afterwards,  in 
which  we  had  the  valuable  assistance  of  Dr.  F.  L.  Parker  (Prof,  of  An- 
atomy), Drs.  W.  M.  Michel,  Buist,  and  others  being  also  present.  It  was 
found  that,  could  the  rupture  have  been  anticipated,  there  would  have  been 
abundant  space  above  the  tumour  to  have  secured  the  common  trunk,  or 
its  external  or  internal  brandies.  The  aneurismal  tumour  was  double, 
the  largest  sac  4^  inches  in  length  and  2  J  in  its  short  diameter;  it 
lay  directly  over  and  external  to  the  artery — the  artery  having  been 
ruptured  about  its  middle  third  through  the  smaller  sac,  which  was  still 
filled  with  clotted  blood  deposited  in  layers  like  an  onion.  This  smaller 
sac — 2  by  3  inches  in  dimensions — was  given  off  from  the  larger,  the 
artery  lying  below  them,  and  this  sac  projected  under  the  lower  jaw.  The 
artery  was  found  to  have  been  tied  scarcely  more  than  a  half  inch  from  the 
aorta,  and  about  an  inch  and  a  half  from  its  entrance  into  the  sac. 

It  will  be  noted  that  we  could  find  only  a  trace  of  the  ligature  ;  it  was 
partly  absorbed,  or  sunk  into  the  substance  of  the  artery.  The  outer  coat 
of  this  last  seemed  to  have  been  cut  into  by  the  ligature ;  it  was  pervious, 
however,  and  there  was  no  clot  in  any  part  of  it.  The  inner  coat  was  not 
cut,  but  only  slightly  congested,  as  it  were,  just  above  the  ligature.  It 
seemed  to  us  that  the  catgut  might  have  come  loose,  or  been  at  least 
slackened  by  the  action  of  the  fluids  to  which  it  was  constantly  exposed — 
though  it  had  been  firmly  tied,  and  for  a  while  seemed  to  serve  its  pur- 
poses. 

We  would  henceforth  be  very  careful  how  we  used  animal  ligatures  in 
operations  so  near  the  heart ;  for  in  this  instance  at  least  we  believe  that 
this  ligature  was  virtually  of  little  use,  perhaps  for  days  before  the  fatal 
hemorrhage  ;  which,  if  we  are  correct,  was  determined  by  the  unrestrained 
current  of  blood  coming  directly  from  the  aorta.  We  do  not  think  that  it 
was  from  any  collateral  circulation  established  at  a  period  subsequent  to 
the  operation  ; — assuredly  not  wholly  from  the  thyroid,  or  the  arteries  at 
the  distal  end  of  the  tumour. 

We  are  much  struck  with  the  confirmatory  objections  very  forcibly 
urged  by  Dr.  E.  W.  Jenks,  of  Detroit,  against  the  use  of  catgut  in  Cesa- 
rean sections. — (See  abstract  of  Dr.  Jenks'  paper  in  the  Quarterly  Sum- 
mary of  this  number  of  the  Journal.) 


1878.] 


451 


REVIEWS. 

Art.  XYII  Tire  Throat  and  its  Diseases.    With  one  hundred  Typical 

Illustrations  in  Colour,  and  fifty  Wood  Engravings,  designed  and  executed 
by  the  Author,  Lennox  Browne,  F.R.C.S.,  Ed.,  Senior  Surgeon  to  the 
Central  London  Throat  and  Ear  Hospital,  Surgeon  and  Aural  Surgeon 
to  the  Royal  Society  of  Musicians,  etc.  8vo.  pp.  xii.,  351.  London: 
Bailliere,  Tindall  &  Cox,  1878. 

The  same.    Philadelphia:  Henry  C.  Lea,  1878. 

Judged  by  the  standard  of  its  literature  alone,  the  progress  made,  espe- 
cially within  the  last  few  years,  in  Laryngology,  has  been  marvellously 
rapid.  If  we  regard  the  publications  of  Morgagni,  made  previous  to  the 
present  century  and  embracing  the  results  of  his  anatomical  and  to  a  cer- 
tain extent  pathological  investigations,  as  the  point  of  development,  it  is 
not  difficult  to  demonstrate  that  they,  incomplete  as  they  perhaps  were, 
were  the  means  of  opening  the  way  to  a  more  correct  appreciation  of 
much  that  prior  to  his  time  was  involved  in  obscurity  and  ignored,  and, 
still  further,  by  exciting  professional  attention  and  stimulating  interest, 
led  in  the  first  half  of  the  present  century  to  an  earnest  seeking  for  the 
truth.  We  recall  to  recollection  works,  many  of  them  even  to-day  classical, 
which  left  their  impress  upon  this  period,  the  studies  of  Miiller  and  Henle 
upon  the  physiology  and  comparative  anatomy  of  the  larynx,  the  valuable 
additions  made  to  the  existing  knowledge  of  its  pathological  anatomy  by 
Cruveilhier,  Rokitansky,  and  Rheiner,  and  to  its  pathology  and  thera- 
peutics by  Cheyne,  Albers,  Ryland,  Porter,  Trousseau,  Belloc,  and  many 
others. 

We  deal  specially,  however,  with  the  period  commencing  with  the  year 
1858,  a  most  eventful  one  in  the  history  of  the  art,  as  results  have  proved. 
The  importance  of  the  physiological  toy  of  Garcia  was  now  seen,  appreci- 
ated, and  utilized  by  the  genius  of  Czermak  and  through  the  labours  of 
Tiirck,  and  the  laryngoscope  was  introduced  into  medical  practice  to 
become'  an  instrument  of  precision  and  an  aid  to  diagnosis,  indispensable 
and  of  immense  power  for  good.  There  is  no  necessity  to  dwell  upon  the 
radical  changes  that  the  little  instrument  at  once  effected  in  all  pre- 
conceived ideas  regarding  the  physiology,  pathology,  and  therapeutics  of 
the  larynx ;  they  are  well  known  and  were  to  be  expected.  Completeness 
of  revelation,  with  favourable  opportunity  for  precision  in  local  treatment, 
worked  their  natural  results,  and  laryngology  became  for  the  first  time 
an  exact  art  and  science. 

With  this  revolution  of  old  ideas  came  naturally  a  new-born  and  in- 
creased stimulus  and  incentive  to  work  on  the  part  of  all  investigators. 
A  new,  practically  untrodden,  and  fruitful  field,  now  illuminated  by  the 
clear  rays  of  the  laryngoscope,  was  open  to  all,  and  the  results  are,  and 
have  been  for  recent  years,  apparent  in  the  literature  of  the  art — a  litera- 
ture which,  according  to  Ziemssen,  abounds  to-day  in  recorded  observa- 
tions to  a  degree  that  is  almost  oppressive.    Aside  from  the  innumerable 


452 


Reviews. 


[Oct, 


monographs  and  articles,  good,  bad,  and  indifferent,  scattered  throughout 
the  journals  of  all  lands,  the  elaborate  works  of  Czermak,  Tiirck,  Von 
Bruns,  Gibb,  Mackenzie,  and  Mandl  stand  forth  as  landmarks  of  progress, 
and  bear  good  and  ample  testimony  to  the  extent  and  excellence  of  the 
work  done  by  the  earlier  observers  with  the  laryngoscope,  while  the  still 
more  rapid  multiplication  of  like  books  within  the  past  year  or  two,  em- 
bracing the  names  of  Fauvel,  Labus,  Zaverthal,  Isambert,  Mauriac,  Mas- 
sei,  Burow,  Von  Bruns,  James,  Browne,  and  others  certainly  seems  to 
argue  favourably  for  a  constantly  increasing  interest  in,  and  a  more  ex- 
tended cultivation  of,  this  important  branch  of  science  ;  for  we  take  it  to 
be  an  evidence  of  a  general  and  healthy  growth  in  any  special  department 
of  medicine,  when  text-books,  such  as  have  been  alluded  to,  works  which 
serve  the  purpose  of  systematic  instruction  for  the  beginner  and  oner  like- 
wise a  reliable  source  of  reference  for  the  practitioner,  are  demanded  and 
produced  in  deference  to  that  demand,  in  more  or  less  rapid  succession. 

The  latest  of  these  works  now  lies  before  us,  and  after  a  careful  exami- 
nation of  it,  our  perusal  being  begun  and  completed,  in  the  full  knowledge 
that  good  text-books  upon  the  subject  of  which  Mr.  Browne  has  written 
already  existed,  we  willingly  record  our  judgment  in  favour  of  the  excel- 
lence of  the  work  that  he  has  done,  and  can  heartily  recommend  his  book 
as  one  eminently  suited  to  meet  the  wants  of  the  class  for  whom  it  is  de- 
signed, viz.,  those  engaged  in  the  active  practice  of  their  profession  ;  and. 
we  will  add,  he  has  done  even  more,  he  has  produced  an  excellent  manual 
for  the  student  and  a  valuable  work  of  reference  for  the  specialist,  a  criti- 
cism that  we  feel  sure  will  be  justified  by  an  examination  of  the  book  in 
question,  and  borne  out  by  many  of  the  characteristics  which  it  presents. 
We  find  within  its  pages  ample  evidence  of  originality  and  depth  of  re- 
search ;  plain  statements,  and  clear  directions,  as  seen  for  instance  in  the 
chapter  on  the  use  of  the  laryngoscope  ;  no  useless  verbiage — but  a  concise 
and  pertinent  expression  of  personal  opinion,  where  it  is  called  for,  as 
shown  at  many  places  throughout  the  work,  but  notably  upon  the  question 
of  the  treatment  of  laryngeal  growths ;  full  information  upon  many  points 
not  usually  found  in  works  of  like  character,  some  sins  of  omission  being 
atoned  for  by  an  explanation  given  in  the  preface  as  to  the  intended  scope 
of  the  work ;  finally,  commendable  care  in  the  collection  of  material,  and 
familiarity  with  the  literature  of  the  specialty,  as  evinced  by  the  frequent 
reference  to  authorities.  The  work  is  also  well  abreast  the  times  in  path- 
ology, as  exemplified  in  the  sections  on  scrofulous  and  tuberculous  ulcera- 
tion of  the  pharynx,  the  identity  or  non-identity  of  membranous  croup 
and  diphtheria,  and  many  other  examples  which  might  be  cited.  Points 
of  excellence  might  still  be  specified,  but  we  believe,  from  what  we  have 
already  indicated,  our  readers  wrill  admit  that  the  volume  is  one  which 
will  repay  an  attentive  perusal. 

Mr.  Browne  has  aimed  to  produce  a  practical  guide  to  the  diagnosis  of 
the  more  ordinary  diseases  of  the  throat  which  may  occur  in  practice,  and 
to  lay  down  lines  for  treatment  which  in  his  experience  have  been  suc- 
cessful. In  this  he  has  certainly  succeeded.  All  those  affections  which 
may  be  considered  peculiar  to  the  throat  have  been  treated  as  fully  as  cir- 
cumstances would  permit,  both  with  reference  to  their  local  symptoms  and 
their  effect  on  the  general  health.  In  the  case,  however,  of  those  dis- 
eases, such  as  diphtheria,  syphilis,  and  phthisis,  which,  although  manifest- 
ing grave  symptoms  in  the  throat,  and  requiring  special  local  treatment, 
are,  in  point  of  fact,  primarily  the  result  of  a  general  poison,  attention 


1878.] 


Browne,  The  Throat  and  its  Diseases. 


453 


has  been  given  principally  to  the  diagnosis  and  treatment  of  the  local 
malady.  Throughout  the  work  his  endeavour  has  evidently  been  to  avoid 
as  far  as  possible  unnecessary  repetition,  and  this  has  been  aided  by  the 
excellent  idea  of  rendering  the  earlier  chapters  so  complete  as  to  make 
them  a  key  to  the  rest  of  the  work.  Histories  in  detail  have  been  pur- 
posely and  wisely  excluded  ;  the  author  being  of  the  opinion,  that  when 
read,  which  is  seldom.,  they  are  but  very  rarely  of  service  to  the  student,  and 
that  clinical  study,  as  the  name  implies,  can  only  be  efficiently  pursued  in 
the  presence  of  the  patient.  Finally,  no  attempt  has  been  made  in  the 
work  before  us  to  discuss  at  unreasonable  length  questions  of  purely 
pathological  interest,  which  would  be  of  but  little  service  to  the  student, 
and  would  only  add  to  the  labour  of  the  reader  without  assisting  him  in  his 
object. 

If  we  now  pass  from  this  rapid  sketch  of  the  general  outline  of  the 
author's  work,  to  the  consideration  of  certain  of  its  details,  giving  prefer- 
ence to  those  of  a  practical  character  as  far  as  possible,  we  find  that  in  his 
opening  chapter  he  at  once  sets  about  the  task  before  Him,  considerately 
sparing  the  reader  the  necessity  of  perusing  the  elaborate  but  time-worn 
dissertation  on  the  history  of  the  laryngoscope,  and  of  the  quarrel  between 
Czermak,  Tiirck,  and  others  concerning  priority  in  the  matter  of  its  in- 
troduction, with  which  most  books  on  laryngoscopy  open,  and  tells  how 
the  laryngoscope  is  to  be  used  and  in  what  it  consists.  He  admits  that  it- 
is  difficult  (and  all  teachers  will  agree  with  him)  to  explain  clearly,  by  a 
mere  verbal  description,  any  process  requiring  technical  apparatus  and 
skill,  and  regards  one  practical  lesson  as  of  more  value  than  a  dozen  pages 
of  written  directions.  As  many  are,  however,  unfortunately  unable  to  avail 
themselves  of  personal  instruction,  he  does  the  next  best  thing,  and  en- 
deavours to  make  the  art  of  using  the  laryngoscope  intelligible  to  them  by 
enumerating  and  describing,  somewhat  dogmatically,  but  still  in  a  manner 
that  is  novel  and  certainly  very  practical,  the  various  steps  that  are  neces- 
sary to  be  taken  in  making  a  laryngoscopic  examination.  He  then  points 
out  the  most  probable  causes  of  failure,  and  gives  the  student  clear  direc- 
tions how  to  best  avoid  those  which  depend  on  the  observer,  and  to  over- 
come those  which  are  due  to  obstacles  pertaining  to  the  patient,  pursuing 
thus,  it  will  be  observed,  precisely  the  same  course  as  would  be  followed 
in  instructing  a  pupil,  with  a  case  before  him.  The  eleven  rules  for  exam- 
ining the  larynx  follow  one  another  in  the  natural  sequence,  and  are,  in 
the  main,  plain  and  explicit,  and  must,  if  followed  out  carefully,  lead,  in 
the  majority  of  instances,  to  success. 

We  note  that  the  author  recommends  that  the  illuminating  apparatus 
shall  be  placed  to  the  left  of  the  patient's  head ;  this  is  contrary  to  the  usual 
custom  as  followed  here  and  in  Germany,  and  possesses  some  disadvantages, 
such  as  the  interference  of  the  right  hand,  the  one  commonly  used  to  in- 
troduce the  mirror,  with  the  rays  of  light  as  they  pass  from  the  lamp  to 
the  forehead  reflector,  which  is  obviated  if  the  light  be  placed  to  the  right 
of  the  patient.  To  catch  the  rays  of  light  upon  the  forehead  reflector  and 
to  direct  them  with  the  proper  focus  upon  the  laryngeal  mirror,  has  in  our 
experience  always  been  a  matter  of  considerable  difficulty  to  the  student. 
Rule  fifth,  which  simply  states  that  the  reflected  light  shall  be  thrown  upon 
the  back  of  the  fauces,  might,  it  seems  to  us,  have  been  made  more  ex- 
plicit by  a  careful  description  of  how  it  can  and  should  be  done. 

The  rules  for  overcoming  certain  difficulties  which  pertain  to  the 
observer,  and  which  follow,  can  be  commended.    They  are  excellent,  and, 


454 


Reviews. 


[Oct. 


as  is  plain  to  see,  are  the  practical  outcome  of  a  long  experience  in  the  use 
of  the  instrument.  While  they,  however,  will  be  of  assistance,  the  be- 
ginner must  be  reminded  again  that  experience  is  the  great  teacher,  and 
cannot  be  entirely  superseded  by  any  directions  or  rules,  however  good  and 
explicit.  The  treatment  of  the  difficulties  presented  by  the  patient,  being 
either  mental,  the  result  of  nervousness,  or  more  rarely  physical,  requires  a 
different  course;  and  we  must  cordially  support  the  author's  statements, 
that  the  gentle  hand  and  encouraging  word  will  do  more  than  any  other 
training,  and  that  all  mechanical  appliances  for  fixing  the  patient  are  to  be 
avoided.  For  the  possible  comfort  of  amateur  laryngoscopists  it  may  be 
added,  that  intolerance  to  laryngoscopy  may  be  caused  by  the  disease,  such 
as  phthisis,  chronic  disease  of  the  pharynx,  etc.,  from  wliieli  the  patient 
suffers,  and  that  the  observer  may,  therefore,  unfairly  accuse  himself  of 
awkwardness. 

In  the  short  section  devoted  to  rhinoscopy,  many  of  the  rules  already 
given  for  laryngoscopy  are  not  repeated,  although  they  are  equally 
necessary,  but  are  supplemented  by  such  additional  ones  as  are  rend*  red 
imperative  by  the  nature  of  the  procedure,  associated  with  suggestions 
for  overcoming  certain  peculiar  difficulties  caused  by  the  natural  conforma- 
tion of  the  parts.  We  observe  that  no  directions  are  given  for  depressing 
the  tongue  during  the  performance  of  the  act ;  on  the  contrary,  the  use  of 
the  tongue  spatula  is  ignored,  and  a  valuable  means  of  assistance  to  ob- 
taining a  perfect  picture  of  the  parts  is  therefore  lost.  Further,  we  cannot 
indorse  the  author's  views  concerning  the  great  value  of  a  digital  exami- 
nation of  the  posterior  nares,  and  question  very  much  whether  this  pro- 
cedure, extensively  employed  by  William  Meyer,  of  Copenhagen,  ever 
affords  satisfactory  and  reliable  results. 

In  glancing  back  at  the  brief  account  which  is  given  of  the  laryngoscope 
itself,  we  find,  that,  very  properly  we  think,  no  detailed  account  of  the 
many  different  methods  of  examining  by  direct  and  indirect  illumination 
is  given  to  confuse  the  student;  there  is  certainly  nothing  to  be  gained  by 
such  a  description,  the  method  by  indirect  or  reflected  light  has  long  since 
been  found  to  be  the  most  generally  applicable,  and  therefore  the  most 
practical  means.  As  a  source  of  light,  gas  is  recommended  ;  but,  it  might 
have  been  added,  sunlight  is  occasionally  of  value  for  the  purpose  of  cor- 
rectly determining  the  natural  colour  of  the  parts,  and  for  the  examination 
of  the  deeper  parts  of  the  trachea.  The  description  of  the  forehead  reflector 
and  of  the  laryngoscopic  or  faucial  mirror  calls  for  no  comment,  though 
we  remark  that  the  author  still  clings  to  the  (to  us)  awkward  spectacle 
frame  as  a  means  of  support  for  the  former  ;  and  we  pass  to  the  admirable 
exposition  of  the  optical  laws  involved  in  the  art  of  laryngoscopy,  which 
we  find  upon  page  10.  So  much  has  been  written  upon  this  subject, 
simple  as  it  is,  and  so  various  and  so  elaborate  are  the  explanations  given, 
that  we  have  often  not  at  all  wondered  that  the  student  should  become 
completely  mystified  while  wading  through  page  after  page  of  their  at- 
tempted demonstration.  There  can  be  no  misconception  in  the  simple 
statement  of  the  author,  that  the  reflected  image  (as  seen  in  the  mirror) 
"  is  laterally  symmetrical  of  the  object  and  not  reversed  ;  that  is  to  say, 
what  is  right  and  left  in  the  larynx  of  the  patient,  remains  right  and  left 
in  the  mirror.  At  the  same  time,  it  must  of  course  be  remembered  that 
the  patient's  right  corresponds  with  the  observer's  left,  and  vice  versd. 
The  only  inversion  which  takes  place  is  in  the  antero-posterior  direction — 
the  epiglottis,  which  in  the  patient's  larynx  is  in  front,  nearest  the  ob- 


1878.]  Browne,  The  Throat  and  its  Diseases.  455 


server,  appearing  at  the  upper  part  of  the  mirror,  whilst  the  posterior  part 
of  the  larynx  appears  in  the  lower  part  of  the  mirror."  And  to  render 
assurance  doubly  sure,  and  make  the  matter  still  clearer,  a  diagram  illus- 
trative of  the  simple  and  well-known  optical  law  upon  which  laryngoscopy 
is  based  is  added. 

Although  it  is  beyond  the  scope  of  his  work,  written  as  it  is  for  advanced 
students  and  practitioners  of  medicine,  to  discuss  in  detail  the  anatomy 
and  physiology  of  the  larynx,  the  author  justly  holds  that  some  brief  ac- 
count of  its  structure  and  uses  is  essential  to  a  right  comprehension  of  the 
laryngoscopy  image,  as  well  as  of  the  changes  made  by  disease,  both  in 
tissue  and  function,  as  viewed  with  the  laryngeal  mirror ;  he  therefore,  in 
a  short  and  comprehensive  chapter  (II.),  gives  all  that  it  is  really  essen- 
tial to  know,  although  some  details,  notably  the  muscular  apparatus  of 
the  larynx,  have  been  treated  rather  superficially,  and  thus  prepares  the 
way  for  an  intelligent  recognition  of  the  various  parts  of  the  image,  seen 
in  the  laryngeal  mirror,  which  are  described  in  the  chapter  which  follows 

(in.) 

The  idea  of  analyzing  and  classifying  the  symptoms  common  to  all  forms 
of  throat  disease,  in  a  preliminary  chapter  (IV.),  is  an  excellent  one,  and 
one  that  is  original  with  the  author ;  it  can  but  save  much  time,  and  will 
undoubtedly  lead  to  a  much  clearer  appreciation  of  the  rational  history  of 
disease,  as  we  find  it  detailed  in  the  subsequent  chapters.  The  practitioner 
is  advised,  for  instance,  in  taking  a  case  of  throat  disease,  after  the  usual 
questions  of  identity,  and  of  predisposing  and  exciting  causes,  to  classify  the 
symptoms  under  the  following  headings :  "A.  Functional  or  Subjective, 
including  impairment  of  the  functions  of  voice,  respiration,  deglutition, 
and,  in  many  pharyngeal  diseases,  of  the  special  senses  of  hearing,  smell, 
and  taste  ;  the  phenomena  of  cough  and  the  amount  and  character  of  ex- 
pectoration and  of  mucous  and  salivary  secretion.  Pain,  irrespective  of 
exercise  of  function,  and  nervous  phenomena,  such  as  that  known  by  the 
term  globus  hystericus,  may  also  be  considered  under  this  heading.  B. 
Physical  or  Objective,  embracing  all  the  appearances  viewed  by  the  ob- 
server within  the  throat,  special  reference  being  given  to  alterations  in 
color,  form,  and  position.  C.  Miscellaneous  and  Commemorative,  which 
include  those  presented  on  external  examination,  as  well  as  those  which 
atf'ect  the  constitution  generally.  Here  may  also  be  included  examination 
of  the  chest,  of  the  auditory  apparatus,  and  of  the  nasal  passages." 

The  details  of  each  of  the  various  classes  of  symptoms  are  systematically 
considered  as  the  chapter  proceeds.  Here  and  there  throughout  the  pages 
which  the  subject  occupies,  we  find  scattered  bits  of  advice,  so  good  and 
so  true,  that  we  are  tempted  to  quote  them.  In  speaking  of  the  symptom 
nasal  respiration,  for  instance,  the  statement  is  made  that  "  no  examina- 
tion of  the  throat  is  complete  without  careful  inspection  of  the  nasal  pas- 
sages through  both  anterior  and  posterior  nostrils ;"  though  it  is  added, 
"  these  are  points  much  neglected  both  in  precept  and  practice ;"  and, 
again,  when  upon  the  subject  of  impairment  of  hearing,  "  All  surgeons 
who  would  be  thoroughly  acquainted  with  the  study  of  throat  diseases 
should  also  acquire  facility  in  examining  the  auditory  apparatus,  and 
should  be  able  to  recognize  the  importance  of  at  least  the  more  common 
variations  in  the  appearances  of  the  drum  head,  the  value  of  tests  by  watch 
and  tuning-fork,  and  how  to  pass  a  Eustachian  catheter,  or  to  use  a  Politzer 
air-bag."  This  view,  in  which  all  intelligent  surgeons  will  agree,  is  like- 
wise interesting  as  bearing  upon  a  question,  which  we  shall  probably  be 


456 


Reviews. 


[Oct. 


called  upon  ere  long  to  decide,  namely,  the  union  of  the  specialties  of 
laryngology  and  otology,  two  departments  which  are  so  intimately  con- 
nected "  that  it  is  difficult  to  comprehend  how  an  aurist  can  work  satisfac- 
torily without  understanding  the  throat,  or  how  one  who  occupies  himself 
with  diseases  of  the  latter  region  can  fail  sometimes  to  be  at  a  loss,  unless 
he  has  worked  also  at  aural  surgery." 

Under  the  third  section,  devoted  to  miscellaneous  and  commemorative 
symptoms,  we  find  still  another  important  point — one  often,  it  is  unfortu- 
nately true,  neglected  by  specialists — insisted  upon  as  follows:  "  The  state 
of  the  tongue,  the  pulse,  the  temperature,  the  appetite,  and  nutrition,  the 
action  of  the  liver,  kidneys,  and  uterus  are  all  of  as  much  importance  in 
laryngeal  disease  as  in  any  other.  Tins  point  is  one  to  be  remembered, 
as,  in  many  cases,  the  special  method  of  examination  seems  to  tell  us  so 
much  that  we  feel  inclined  to  make  a  diagnosis  of  the  malady  without  ask- 
ing a  question  of  the  patient."  And  here,  likewise,  is  the  utility  of  ex- 
ternal examination  of  the  larynx,  of  stethoscopic  examination  of  the  lungs, 
of  the  use  of  the  sphygmograph  and  of  the  ophthalmoscope,  referred  to  as 
most  important  aids  to  the  observer  in  making  up  his  diagnosis. 

In  Chapter  V.  the  reader's  attention  is  directed  to  the  subject  of  laryn- 
geal therapeutics — medical,  surgical,  dietetic,  and  hygienic;  and  much 
that  is  of  interest  is  naturally  met  with  in  its  perusal.  The  author's  views 
on  the  broad  question  may,  perhaps,  be  best  learned  by  giving  one  or  two 
of  the  opening  paragraphs,  premising  that  though  special  attention  is  ne- 
cessarily given  throughout  the  chapter  to  those  remedies  and  methods 
of  treatment  which  have  a  topical  action,  the  reader  must  not  suppose,  on 
this  account,  that  general  treatment  in  diseases  of  the  throat  is  unneces- 
sary; on  the  contrary,  according  to  the  author's'experience,  which  will  be 
in  accord  with  that  of  all  other  laryngologists,  it  is  often  equally  futile 
to  treat  throat  disease  by  only  topical,  as  it  is  by  only  general  means. 
"  In  employing  topical  remedies  it  is  always  well  to  bear  in  mind  the 
physiological  functions  of  the  part  to  which  the  remedy  is  to  be  applied. 
For  instance,  the  function  of  the  larynx  being  to  afford  passage  to  air, 
and  not  to  liquids,  the  use  of  sprays  to  this  part  is,  in  the  author's  opinion, 
a  mistake."  With  this  opinion  we  cannot  assent.  The  laryngeal  spray- 
tube,  used  with  a  high  pressure  of  compressed  air,  has  entirely  superseded, 
in  our  hands,  the  use  of  the  laryngeal  brush,  and  with  the  best  results. 
There  can  be  no  question  regarding  the  thoroughness,  comfort,  and  even 
elegance  of  the  method.  "  Vapor  inhalations  are  much  more  suitable,  and 
more  in  accordance  with  the  natural  function  of  the  organ.  The  same 
may  be  said  of  the  practice  of  blowing  powders  into  the  larynx  or  the 
administration  of  snuffs  in  nasal  diseases.  They  are  entirely  unphysiolo- 
gical,  seldom  beneficial,  and  often  deleterious.  On  the  same  principle, 
whenever  applications  of  a  liquid  character  are  absolutely  necessary,  only 
a  very  small  quantity  of  the  liquid  should  be  applied  at  a  time,  and  the 
area  of  application  should  be,  as  far  as  possible,  limited  to  the  exact 
portion  affected." 

In  speaking  of  general  treatment  we  are  told — 

' '  That  it  is  always  specially  indicated  when  the  throat  affection  is  symptomatic 
of  any  general  malady — scrofula,  phthisis,  or  syphilis,  for  example — or  when  it 
occurs  in  the  course  of  a  continued  fever,  of  one  of  the  exanthemata,  of  diphthe- 
ria, or  as  a  result  of  zymotic  influences.  In  other  cases,  also,  a  constitutional 
diathesis  must  be  combated  concurrently  with  the  local  trouble.  In  very  many 
local  manifestations,  however,  general  treatment  is,  if  not  contraindicated,  at 
least  unnecessary." 


1878.] 


Browne,  The  Throat  and  its  Diseases. 


457 


The  author  then  proceeds,  for  the  sake  of  convenience  in  discussing 
them,  to  divide  topical  remedies  into  three  classes,  as  follows  :  1.  Those 
which  can  be  administered  by  the  patient  alone,  such  as  gargles,  lozenges, 
powders,  inhalations,  as  well  as  all  kinds  of  external  applications.  2.  Those 
which  can  be  administered  either  by  the  patient  or  the  practitioner,  in- 
cluding pharyngeal  and  nasal  sprays,  insufflations,  douches,  and  external 
or  pharyngeal  pigments.  3.  Those  which,  requiring  the  management  of  a 
skilled  hand,  can  be  administered  by  the  practitioner  only,  in  which  class 
are  contained  laryngeal  applications  of  all  kinds,  except  those  of  the  nature 
of  inhalations,  and  all  forms  of  operative  procedure.  Space  will  not  allow 
us  to  follow  out,  as  carefully  as  we  would  desire,  the  description  of,  and 
criticisms  on,  the  above  methods  of  treatment,  and  we  must,  therefore,  con- 
tent ourselves  with  referring  those  interested  in  the  subject  to  the  original 
article,  where  they  will  find  much  that  is  of  interest,  and  some  views 
which  are  novel. 

With  Chapter  VI.,  devoted  to  diseases  of  the  pharynx  and  fauces,  com- 
mences what  to  many  will  be  one  of  the  most  interesting  portions  of  the 
volume  before  us.  The  subject  is  one  that  is  but  superficially  treated 
of  in  the  majority  of  works  on  throat  diseases ;  and  so  little  really  can 
be  found  in  the  literature  concerning  it  that  is  of  any  value,  that  there 
is  a  certain  satisfaction  in  finding  nearly  one  hundred  pages  of  the  work 
under  review  devoted  to  its  careful  consideration;  and  we  turn  to  them, 
therefore,  with  a  certain  sense  of  satisfaction,  and  in  the  expectation  of 
finding  much  that  is  of  importance,  perhaps  much  that  is  new.  In  this 
expectation  we  premise  we  have  not  been  disappointed.  Passing  over 
the  few  general  considerations  relating  to  the  pharynx  with  which  the 
chapter  opens,  and  the  remarks  on  acute  and  subacute  pharyngitis,  which 
are  judicious  and  practical,  and  sufficiently  comprehensive,  we  pause  at 
that  devoted  to  chronic  inflammation,  to  quote  the  view  held  by  the  author 
concerning  the  connection  of  chronic  pharyngitis  with  certain  diatheses 
and  diseases  of  other  parts :  "  Neither  acne  nor  herpes  plays  an  important 
part  as  a  cause,  as  has  been  stated  by  Isambert  and  other  French  authors." 
Mr.  Browne  "  has  found  many  patients  the  subject  of  chronic  pharyngitis 
who  were  not  subject  to  any  form  of  acne  or  herpes  ;  but  seeing  that  such 
affections,  as  well  as  granular  pharyngitis,  are  due,  in  some  measure,  to 
disorder  of  the  portal  circulation,  it  is  not  surprising  that  they  should  fre- 
quently coexist ;  and  whereas  the  skin  affections  require  little  or  no  local 
treatment,  it  is  certain  that  no  form  of  exclusively  constitutional  treatment 
will  remove  granulations  from  a  chronically  congested  pharynx."  In 
those  cases  the  obstinacy  of  which  under  treatment  is  well  known,  where 
there  is  capillary  engorgement  with  granulations,  he  has  seldom  found  the 
topical  application  of  astringents,  and  the  use  of  astringent  lozenges,  suffi- 
cient for  the  purposes  of  cure,  unless  preceded  by  the  destruction  of  the 
enlarged  vessels  which  supply  blood  to  the  follicles.  "  On  these  vessels 
being  divided  and  obliterated  by  means  of  a  fine  galvano-cautery  point, 
the  follicles  will  be  seen  within  a  very  short  time  to  shrivel  up  and  disap- 
pear. Where  the  galvano-cautery  is  not  available,  the  same  end  may  be 
obtained  by  incising  the  vein  transversely  with  a  long-pointed  knife  or 
lancet,  and  then  applying  a  fine  caustic  point,  with  a  little  pressure  to  the 
cut  spot."  He  does  not  agree  with  those  laryngologists  who  advise  de- 
struction of  the  granules  by  caustic  pastes  (Mackenzie),  by  cautery  wires 
(Michel),  or  by  blunt  cautery  knives  (Reisenfeld)  ;  truly  remarking  that 
such  plans  only  treat  an  effect,  and  cannot  remove  the  cause. 


458 


R  E  V  I  E  W 


[Oct. 


We  find  nothing  new  in  the  section — concise  and  well  written  as  it  is  

on  syphilitic  ulceration  of  the  pharynx,  excepting,  perhaps,  the  fact  that 
the  author,  who  was  formerly  in  the  hahit  of  treating  all  tertiary  ulcera- 
tions by  the  daily  local  application  of  nitrate  of  silver,  etc.,  has  latterly 
met  with  such  marked  success  both  as  to  rapidity  of  cure  and  freedom  from 
recurrence,  from  the  employment  of  the  galvano-cautery,  that  this  measure 
has  largely  superseded,  in  his  practice,  the  use  of  the  mineral  caustics.  But 
we  can  commend  highly  those  chapters  devoted  to  scrofulous  and  tuber- 
culous ulceration  of  the  same  part ;  both  treat  of  conditions  concerning 
which  much  has  of  late  been  written,  and  about  the  pathological  nature  of 
which  many  diverse  views  are  expressed.  These  facts,  and  the  unques- 
tioned rarity  of  the  affections  in  point,  must  make  the  subject  one  of  gene- 
ral interest,  and  the  length  of  our  quotations  embodying  the  author's 
views,  which  are  well  abreast  the  times,  and  representative  of  the  gene- 
rally held  view,  will  therefore,  we  trust,  be  pardonable. 

Concerning  scrofulous  pharyngitis,  described  by  Isambert  and  others  as 
a  quite  distinct  form  of  disease,  3Ir.  Browne  states  that  he 

"  does  not  deny  a  specific  manifestation  of  scrofula  in  the  pharynx  ;  he  only 
affirms  that  it  is  not  usually  one  of  ulceration.  The  form  in  which  he  has  seen 
it  exemplified  is  that  of  a  low  type  of  inflammatory  thickening  of  the  fauces, 
of  the  naso-pharyngeal  passages,  of  the  nasal  septum,  of  the  glands  in  the  vault 
of  the  pharynx,  and  of  the  faucial  tonsils,  accompanied  not  unfrequently  by  a 
similar  condition  of  the  neighbouring  lymphatic  glands,  which  often  undergo 
disintegration.    There  is  also  occasional  necrosis  of  turbinated  bone." 

We  are  indebted  to  Dr.  Frankel,  of  Berlin,  for  the  latest  and  best  con- 
tribution to  the  subject  of  tubercular  ulceration  of  the  pharynx.  His  paper 
{Berliner  Klinische  Wochenschrift,  Nov.  187G)  contains  the  records  of 
several  cases  which  are  adduced  to  support  his  theory  that  "  miliary  tuber- 
culosis of  the  pharynx  is  a  disease  which  attacks  either  apparently  healthy 
persons  or  those  already  affected  with  phthisis  of  other  organs."  Mr. 
Browne  disagrees  with  him,  for  he  tells  us  that — 

"a  very  attentive  perusal  and  careful  consideration  of  the  paper  has  led  the 
author  to  the  conclusion  that  Dr.  Frankel  has  in  no  way  proved  his  case,  especially 
with  regard  to  the  occurrence  of  miliary  tuberculosis  of  the  pharynx  in  appa- 
rently healthy  persons.  In  none  of  the  cases  quoted  is  any  sufficient  evidence 
brought  forward  to  show  that  the  deposit  of  tubercle  in  the  pharynx  preceded  its 
development  in  other  organs  of  the  body,  and  in  most  of  the  cases  the  diagnosis 
of  tubercle  in  the  pharynx  appears  to  have  been  made  only  alter  evidence  of 
advanced  phthisis  had  been  found  elsewhere.  Dr.  Frankel' s  paper,  therefore,  if 
it  proves  anything,  proves  only  this,  that  in  cases  of  tuberculosis,  where  tubercle 
is  deposited  widely  over  the  bod}',  in  almost  every  organ  and  tissue,  the  pharynx 
does  not  always  escape." 

The  devotion  of  several  pages  to  affections  of  the  uvula  may  excite  a 
smile  as  one  remembers  the  time-worn  story  concerning  the  evils  of 
specialism,  but  if  it  be  likewise  remembered  "  that  a  relaxed  uvula  acts 
as  the  excitant,  or  at  any  rate  as  an  aggravator  of  a  long  train  of  most 
inconvenient,  not  to  say  serious  symptoms,  and  serves  to  make  the  throat 
peculiarly  liable  to  catarrhal  attacks,"  no  justification  will  be  necessary 
for  considering  its  diseases  under  a  separate  heading.  Indeed  we  affirm 
that  no  section  of  the  work  before  us  contains  more  valuable  information 
nor  directions  which  if  utilized  will  confer  greater  relief  to  the  patient. 
We  have  Aitken's  authority  for  stating,  that  "  while  hardly  any  slight 
affection  of  the  throat  produces  such  serious  symptoms  as  elongation  of 
the  uvula,  it  is  equally  true  that  there  is  no  slight  operation  that  gives 


1878.] 


Browne,  The  Throat  and  its  Diseases. 


459 


such  complete  and  permanent  relief  as  removal  of  the  elongated  ex- 
tremity." 

In  the  section  treating  of  acute  tonsillitis,  the  following  excellent  ad- 
vice is  given — advice  about  which  there  ought  to  be  no  difference  of  opin- 
ion— it  relates  to  the  question  of  the  proper  time  for  surgical  interference, 
and  the  reader  is  told 

"never  to  inflict  unnecessary  pain  by  useless  scarifications  on  the  surface  of  a 
tonsil  undergoing  general  inflammation.  Never  to  make  deep  incisions  unless 
there  is  almost  certainty  of  advanced  suppuration.  To  remove  the  tonsils  as 
soon  as  they  become  sufficiently  enlarged  in  those  cases  of  recurrent  quinsy  in 
which  there  is  not  chronic  enlargement,  but  in  which  the  tonsil,  though  diseased, 
is  too  small  for  excision,  except  on  occurrence  of  the  acute  inflammation.  By 
this  means  the  disease  is  at  once  cut  short,  and  the  chance  of  further  recurrence 
avoided.  To  recommend  removal,  on  subsidence  of  the  attack,  of  tonsils  chroni- 
cally enlarged  and  liable  to  quinsy." 

Chronic  enlargement  of  the  tonsils  is  only,  the  author  believes,  to  be 
satisfactorily  treated  by  the  one  method  of  excision,  and  there  does  not 
appear  to  him  to  be 

"any  valid  reason  why  there  should  be  two  opinions  on  the  question;  the 
operation  is  simple,  and  is  accompanied  with,  little  pain  ;  the  result  is  speedily  and 
always  permanently  beneficial.  All  measures  of  local  applications,  'removal 
without  cutting'  by  caustic  pastes,  injections  into  the  substance  of  the  gland  are 
useless,  and  some  of  them  barbarous." 

In  these  statements  we  fully  coincide,  and  our  experience  leads  us  like- 
wise to  endorse  most  fully  the  positive  answer  which  he  gives  as  to  the 
results  which  can  follow  the  operation  :  u  Nothing  but  good  can  come  of 
it  in  suitable  cases."  Still  every  specialist  knows  well  how  often  he  is 
asked  the  questions  :  Are  any  ill  effects  likely  to  take  place  after  removal 
of  the  tonsils?  Will  the  patient  be  more  liable  to  suffer  from  cold,  or  to 
contract  such  diseases  as  diphtheria?  and  will  the  voice  be  likely  to  suffer? 

Catarrhal  inflammation  of  the  naso-pharynx,  or  post-nasal  catarrh 
(Chap.  VIII.) ,  next  claims  our  attention — a  subject  that  is  of  much  in- 
terest to  all  specialists,  notably  so  in  this  country,  and  one  upon  which 
little,  until  recently,  has  been  written  that  has  practical  worth.  Even 
now.  all  will,  we  believe,  agree  with  us,  that  there  is  still  an  abundance 
of  room  for  improvement  in  our  treatment  of  the  affection,  and  that 
though  its  natural  history  and  symptomatology  are  well  known  to  us,  our 
efforts  for  its  radical  cure  are  not  as  successful  as  we  could  desire  them  to 
be.  We  pass  by,  therefore,  in  the  present  chapter  the  description  of  symp- 
toms, as  offering  nothing  specially  worthy  of  notice — simply  remarking 
that  the  author  has  alluded  to  them  generally,  and  made  brief  notes  here 
and  there  of  special  points  of  distinction,  and  come  to  the  matter  of  treat- 
ment. Here  we  find  certain  novel  and  original  suggestions.  The  general 
plan  we  may  briefly  outline  as  follows  :  The  author  believes  that  the 
best  method  at  the  commencement  of  treatment  of  a  case  of  post-nasal 
catarrh  is  to  employ  steam  inhalations,  soothing  or  stimulating  accord- 
ing to  the  indications.  Lozenges,  calculated  to  promote  salivary  secre- 
tion, applications  of  vaseline  with  three  to  five  grains  of  carbolic  acid 
and  iodine  to  each  ounce,  and  with  atropia  when  there  is  a  tendency 
to  recurring  coryza,  and  finally  applications  of  iodoform  in  ether  or 
vaseline  when  there  is  hyperemia  and  thickening.  Constitutional  treat- 
ment is  all  important,  and  is  always  to  be  associated  with  the  local  mea- 
sures.   Iron  phosphates,  phosphorized  cod-liver  oil,  and  hydrochlorate  of 


460 


Reviews. 


[Oct. 


ammonia  with  cinchona  are  his  favourite  means.  When,  however,  the  dis- 
ease has  been  of  such  long  standing  that  excoriation  or  ulceration  of  the 
mucous  membrane  and  submucous  tissue  of  the  nasal  passages  or  even 
necrosis  of  the  turbinated  bones  has  taken  place,  something  more  than 
the  above  measures  is  required  ;  the  posterior  nasal  douche  is  now  recom- 
mended, and  the  galvano-cautery  used.  Mr.  Browne  has  been  encouraged 
to  employ  the  latter  in  cases  which  present  the  "  hypertrophic  form  of  post- 
nasal catarrh  with  thickening  of  the  tissues  attached  to  the  vomer,  with 
or  without  granulations  at  the  vault  of  the  pharynx,"  by  the  success 
which  has  attended  operations  in  this  region  by  its  means;  and  therefore 
has  discontinued  in  his  practice  the  use  of  all  mineral  caustics,  which,  he 
holds,  tend  rather  to  irritate  to  fresh  inflammation  (though  we  cannot  see 
why  they  should  any  more  than  the  cautery  iron)  and  to  new  growth;  all 
cutting  operations,  which  he  holds  are  inadmissible  on  account  of  hemor- 
rhage (rather  a  trivial  reason  apparently)  ;  and  finally  dilatation,  which, 
as  he  truly  says,  is  ineffectual  and  most  painful.  We  are  fully  in  accord 
with  him  in  his  praise  of  the  galvano-cautery  as  a  means  of  treating  these 
difficult  cases ;  it  is,  however,  not  a  sole  means.  We  have  found  nitric 
and  chromic  acid,  preferably  the  former,  as  less  disagreeable  in  its  imme- 
diate effects,  to  answer  the  same  purpose,  and  with  them  have  attained  as 
equally  good  results  as  with  the  cautery;  the  latter  again  will  be  objected 
to  most  strenuously  by  many  patients. 

We  find  the  ordinary  nasal  douche  condemned  ;  the  reasons  given  being 
that  it  does  not  do  its  work  efficiently,  that  it  produces  pain,  and  that  it  is 
liable  to  cause  inflammation  of  the  middle  ear,  and  that  it  is  therefore 
supplanted  in  the  author's  practice  by  the  posterior  nasal  douche,  which 
latter,  judging  from  the  text,  we  should  regard  as  a  remarkably  efficient 
instrument,  did  we  not  find  further  on  the  statement  made,  to  our  surprise, 
considering  its  previous  condemnation,  that  ''the  anterior  douche  [may 
be]  made  to  continue  the  treatment  effectively  commenced  by  the  pos- 
terior." No  mention  is  made  of  the  use  of  the  anterior  nasal  sprays 
(Lefferts.  Rumbold)  for  the  purpose  of  irrigating  the  nasal  passages  and 
pharyngeal  space,  which  have  in  this  country  largely  supplanted  the  use  of 
the  nasal  douche,  and  justly  so. 

In  Chapter  IX.  we  have  the  important  topic  of  diphtheria  presented  to 
us.  The  author  makes  no  attempt  to  decide  the  vexed  question  as  to  its 
identity  or  non-identity  with  membranous  croup  so  far  as  the  broad  general 
question  is  concerned,  stating  that  he 

"hesitates  to  give  an  opinion  contrary  to  that  of  many  eminent  physicians, 
headed  by  Sir  Thomas  Watson  and  Sir  William  J enner.  in  England,  and  of  such 
careful  observers  as  Bretonneau,  Trousseau.  Oertel,  Steiner,  etc.,  abroad,  but  he 
feels  it  incumbent  upon  him  to  draw  attention  to  certain  local  evidences  of  the 
disease  which  appear  to  offer  well-marked  distinctions  between  diphtheria  and 
membranous  croup,  or  membranous  laryngitis,  as  it  is  termed  in  modern  pa- 
thology ;  and  also  to  certain  general  constitutional  symptoms  believed  to  be 
equally  distinctive,  which  present  themselves  during  the  time  the  local  condition 
is  under  observation  and  treatment." 

His  consideration  of  the  affection  is  then,  we  find,  principally  limited 
to  an  enumeration  and  description  of  such  local  symptoms  and  signs  as 
will  best  assist  the  practitioner  in  making  an  early  diagnosis.  As  regards 
local  treatment  he  tells  us  that  the  most  satisfactory  applications  in  his 
practice  have  been  those  of  lime-water,  lactic  acid,  carbolic  acid,  and  the 
sulpho-carbolates,  as  advised  by  Dr.  Sansom  ;  he  has  had  no  experience 


1878.] 


Browne,  The  Throat  and  its  Diseases. 


461 


in  the  use  of  sulphurous  acid,  and  denounces  the  employment  of  caustic 
solutions,  especially  nitrate  of  silver,  emetics,  or  mechanical  attempts  to 
tear  away  the  false  membrane.  Upon  the  question  of  tracheotomy  he  is 
not  very  positive,  simply  observing,  that  if  it  is  to  be  performed,  it  should 
not  be  delayed  too  long,  and  that  it  has  one  strong  reason  in  its  favour, 
viz.,  that  even  if  it  does  not  save  the  patient's  life,  it  does,  in  a  very 
marked  degree,  diminish  the  agony  of  death,  as  well  as  lessen  the  distress 
of  those  surrounding  the  bedside  of  the  sufferer. 

With  Chapter  X.  commences  the  consideration  of  the  diseases  of  the 
larynx,  and  the  pathology,  symptomatology,  and  treatment  of  anaemia, 
hyperamiia,  acute  laryngitis,  simple  oedema,  subacute  laryngitis,  and  chronic 
laryngitis.  Under  this  latter  head  are  included  the  laryngeal  manifesta- 
tions of  syphilis  and  tubercle,  which  are  in  turn  systematically,  fully,  and 
clearly  presented  to  the  reader.  There  is  nothing  under  the  majority  of 
these  headings  which  requires  any  special  notice  on  our  part,  the  text  being 
sufficiently  full  on  all  the  different  subjects ;  they  will  merit  careful  perusal, 
and  will  be  found  to  be  of  practical  value  and  assistance  to  those  seeking 
information  on  the  subjects  of  which  they  treat.  Under  the  title  of  "  Acute 
Laryngitis"  we  find  the  recommendation  "that  where  a  satisfactory  laryn- 
goscopy examination  cannot  be  made  in  young  children,  the  diagnosis  may 
be  aided  by  the  introduction  of  the  .finger  into  the  larynx."  The  author 
adds  that  such  a  course  is  to  be  deprecated,  and  most  sparingly  employed. 
Still  we  confess  that  we  are  surprised  that  he  should  ever  advise  recourse  to 
such  a  procedure,  and  certainly  fail  to  see  of  what  possible  aid  it  can  be, 
even  in  oedema.  The  question  is  often  asked,  whether  there  is  danger  of  a 
simple  chronic  laryngeal  catarrh  running  into  the  tubercular  form,  and 
our  author  admits  that  the  fear  "  is  a  great  source  of  anxiety,"  and  recom- 
mends a  guarded  prognosis,  especially  if  there  be  the  slightest  tendency  to 
phthisis  in  the  patient's  family. 

Under  the  same  head  the  treatment  of  chronic  laryngitis  is  briefly 
discussed.  Here  we  find  the  advice  given,  to  us  novel,  that  "in  many 
cases  where  the  mental  anxiety  has  almost  gone  to  the  length  of  hypo- 
chondriasis, bromide  of  potassium  has  been  found  of  the  greatest  utility. 
In  other  cases,  five  grain  doses  of  hydrate  of  chloral  have  an  admirable 
effect  in  calming  the  mind,"  advice  which  would  seem  to  indicate  that  our 
British  brethren  are  more  liable  to  depression  of  spirits  than  their  American 
cousins ;  the  latter,  if  our  experience  is  any  criterion,  bearing  up  well  under 
the  infliction  of  a  chronic  inflammation  of  their  vocal  organs. 

Again  we  are  called  upon  to  note  the  apparent  great  faith  of  our  author 
in  inhalations  and  lozenges  as  a  means  of  medication ;  a  fact,  which  we 
have  several  times  remarked  in  following  out  his  plan  of  treatment  for  the 
various  affections  which  have  been  already  considered.  We  are  somewhat 
sceptical  concerning  their  usefulness,  and  regard  them  as  being  of  very 
limited  applicability ;  an  opinion  that,  we  believe,  will  be  borne  out,  not 
only  by  our  experience  but  that  of  many  others  as  well.  The  local  astrin- 
gent solution,  which  he  has  found  to  be  most  generally  serviceable,  is  that 
of  chloride  of  zinc,  applied,  we  suppose,  by  means  of  the  laryngeal  brush, 
although  the  particular  method  is  not  stated;  and  we  observe  with  pleasure 
that  the  direction  is  added,  that  the  application  must  be  made  with  the  aid 
of  the  laryngeal  mirror.  This  is  as  it  should  be,  and  some  may  be  surprised 
to  learn  that  it  is  not  always  so ;  it  is,  howrever,  not  so  many  years  since 
we  saw  at  the  Hospital  for  Diseases  of  the  Throat,  in  London,  cases  treated 
by  the  laryngeal  brush,  without  the  aid  of  the  mirror,  and  this  as  a  rule. 


462 


Reviews. 


[Oct. 


We  would  willingly  pause  to  analyze  the  very  excellent  chapter  (XI.) 
relating  to  secondary  and  tertiary  syphilis  of  the  larynx,  but  time  and 
space  oblige  us  to  pass  on  to  the  equally  interesting  one  on  the  subject  of 
tubercular  disease  of  the  organ  (XII.).  The  diverse  views  which  are  held 
to-day  concerning  the  true  pathology  of  tubercular  laryngitis,  must  be  our 
excuse  for  quoting,  without  comment,  the  opinion  of  one  who  has  had  ample 
opportunity  for  practical  observation,  somewhat  in  extenso. 

"That  evidence  of  the  tubercular  diathesis  influences  a  local  laryngeal  inflam- 
mation in  a  manner  eminently  characteristic,  and  at  a  period  long  prior  to  the 
discovery  of  equally  well-marked  symptoms  in  the  lungs,  is  a  fact  which  the  daily 
observation  of  those  engaged  in  laryngeal  practice  establishes  as  incontrovertible. 

''Whether  or  not  there  be  tubercle  actually  developed  in  the  larynx,  or  what 
indeed  is  the  nature  of  tubercle  wherever  developed,  the  author  does  not  presume, 
and  indeed  does  not  care,  to  decide.  Seeing,  however,  that  tuberculosis  is  a 
disease  primarily  manifesting  itself  more  especially  in  the  respiratory  organs : 
seeing  that  catarrh  is  one  of  the  most  frequent  excitants  to  that  disease,  and  that 
many  catarrhal  inflammations  of  the  lungs  commence  in  the  larynx,  it  is  at  least 
fair  to  infer  that,  in  those  cases  in  which  the  eye  reveals  what  has  come  to  be 
recognized  as  tuberculous  laryngitis  before  the  ear  detects  the  presence  of  tubercle 
in  the  lungs,  the  disease  has  primarily  attacked  the  former  organ.  Not  only  so, 
but  noting  also  that  the  morbid  changes  in  the  larynx,  as  physically  evidenced  in 
every  stage,  are  quite  different  from  those  of  simple  catarrhal  and  of  syphilitic,  to 
say  nothing  of  exanthematous  and  other  phlegmonous  inflammations,  it  is  not  un- 
reasonable to  suggest  that  the  factors  are  also  of  an  equally  distinctive  character. 

"  It  is  quite  certain  that  the  pale,  opaque  tumefaction  of  the  arytenoid  carti- 
lages and  of  the  epiglottis  in  laryngeal  phthisis,  has  not  the  clear  transparency  of 
serous  (edema,  the  active  glandular  inflammation  of  simple  laryngitis,  the  hyper- 
plastic infiltration  of  syphilis,  or  the  angry  inflammatory  irritation  of  carcinoma. 
Nor  is  the  consequent  ulcerative  process  less  distinctive  ;  there  is  not  erosion,  nor 
deep  excavated  circumscribed  ulcers,  followed  by  narrowing  cicatrices  ;  nor  new 
formations  taking  on  an  ulcerative  process,  but  a  true  carious  degeneration,  causing 
loss  of  tissue,  which,  commencing  superficially  at  small  points,  leads  to  universal 
destruction  of  the  deeper  parts,  without  extension  to  neighbouring  glands,  and  with 
but  feeble,  if  any,  attempt,  under  treatment,  at  a  reparative  process. 

"  It  is,  therefore,  surprising  that  we  should  be  told  with  reference  to  laryngeal 
phthisis,  on  the  one  hand,  that  '  tubercle  appears  to  play  a  very  secondary  part, 
if  any  part  at  all'  in  its  production  (Mackenzie)  ;  and  on  the  other  4  that  neither 
the  catarrh  nor  the  ulceration  of  phthisical  subjects  presents  any  characteristic 
signs  by  which  it  could  be  recognized  as  such,  [and  that]  the  attempts  made 
to  establish  pathognomonic  peculiarities  cannot  be  said  to  have  succeeded.' 
(Ziemssen.) 

"  We  prefer  to  adopt  the  view  of  Virchow,  who  just  exactly  recommends  the 
larynx  as  the  most  appropriate  place  for  the  study  of  true  tubercle. ' ' 

In  respect  to  a  local  treatment  for  the  disease,  although  we  coincide  in 
the  statement  that  the  greatest  relief  can  be  given  by  suitable  applications, 
and  think  that  they  should  always  be  employed,  we  cannot  bear  testimony 
as  to  the  value  of  all  the  means  adopted  by  the  author.  We  fear,  for  instance, 
that  more  harm  than  benefit  will  often  result  to  an  inflamed  and  highly 
irritated  larynx — one,  we  must  remember,  prone  to  take  on  destructive 
changes  at  the  slightest  provocation — from  the  necessary  amount  of  mechan- 
ical irritation,  however  slight,  that  will  be  caused  by  the  introduction  of  a 
brush,  and  our  rule  has  always  been  in  this  class  of  cases  to  make  our  treat- 
ment as  mild  and  as  unirritating  as  is  possible,  consistent  with  efficiency. 
To  this  end,  we  are  in  the  habit  of  making  our  applications,  with  certain 
exceptions,  by  means  of  the  spray  with  compressed  air,  and  have  found  it 
to  fulfil  all  indications.  Nitrate  of  silver  the  author  condemns,  and  very 
properly  so  in  many,  perhaps  the  majority  of,  instances.    We  find,  how- 


1878.] 


Browxe,  The  Throat  and  its  Diseases. 


463 


ever,  excellent  evidence  in  favour  of  its  use,  in  certain  recent  articles 
(Sawyer,  Marcet),  and  must  add  that  with  us  it  has  certainly  worked 
wonders  in  relieving  the  terrible  dysphagia  so  often  present  in  advanced 
cases  of  the  disease,  when  all  other  and  milder  measures  had  failed. 

Inhalations,  lozenges,  etc.,  which  are  recommended,  afford  but  a  very 
temporary  relief ;  the  patient  demands  something  more.  Chloride  of  zinc, 
which  is  mentioned  as  the  most  comforting  solution,  often  acts  well. 
Glycerine  of  tannin  has  with  us  been  useless.  Bismuth,  gum,  and  morphia 
is  an  application,  as  the  author  truly  says,  of  much  value  ;  administered  in 
powder  by  insufflation,  and  forming,  it  will  be  noticed,  an  exception  to  his 
general  condemnation  of  this  method  of  administering  remedies.  We  find 
no  allusion  to  the  application  of  iodoform  and  morphia  in  powder  or  in 
spray,  a  more  efficacious  remedy  than  the  preceding,  nor  to  the  iodine  and 
almond  oil  mixture  of  Marcet. 

We  must  also  take  exception  to  his  advice  in  relation  to  the  operation 
of  tracheotomy  in  advanced  cases  of  tubercular  laryngitis,  for  he  says, 
somewhat  severely,  when  discountenancing  it — 

"that  it  was  not  unfrequently  performed,  in  pre-laryngoscopic  times,  on  pa- 
tients who  were  the  subjects  of  laryngeal  phthisis  ;  for  this  there  was  the  excuse 
of  ignorance  of  the  actual  local  condition  ;  but  the  same  measure  has  been  adopted 
even  by  practitioners,  who,  using  the  laryngoscope,  should  have  been  aware  of 
the  futility  of  such  a  procedure." 

The  operation  cannot,  of  course,  be  curative;  but  it  can,  and  is  often, 
most  markedly  and  mercifully  palliative.  We  believe  that  there  are  many 
cases  constantly  occurring  where  it  is  imperatively  demanded  at  the  con- 
scientious surgeon's  hands — cases  in  which  the  indications  for  the  opera- 
tion are  based  upon  common  surgical  principles,  and  where  the  relief 
which  it  will  afford  is  not  only  great,  but  life  itself  is  prolonged  for  a 
period  extending  far  beyond  the  limit  "  of  a  few  days  or  weeks."  We 
have  a  personal  knowledge  of  such  instances,  and  venture  to  recall  to  our 
author's  recollection  the  similar  experience  of  Seckowiski,  Elsberg,  Smith, 
Janeway,  Ripley,  and  others. 

The  subject  of  the  treatment  of  benign  neoplasms  in  the  larynx  byintra- 
laryngeal  operation  (Chapter  XIV.)  calls  forth  a  most  decided  expression 
of  opinion  from  the  author.  His  views,  as  will  be  seen,  vary  widely  in 
many  respects  from  those  which  are  commonly  held,  and  are,  to  say  the 
least,  often  debatable ;  they  are,  however,  so  honestly  stated,  and  bear  the 
impress  of  such  earnest  thought  and  sincere  conviction,  that  they  will  ex- 
cite much  attention  and  interest,  and  will  perhaps  serve  their  purpose  "of 
inducing  members  of  the  profession  to  withhold  their  hands  from  efforts  at 
mechanical  removal  of  what  is  often,  in  every  sense,  a  most  benign  forma- 
tion." They  may  be  clearly  gathered  from  the  perusal  of  certain  proposi- 
tions which  he  offers  for  the  consideration  of  the  reader,  and  which  may, 
therefore,  though  they  have  already  been  brought  under  the  notice  of  the 
profession  in  a  paper  read  before  the  Medical  Society  of  London,  and  pub- 
lished in  the  British  Medical  Journal  of  May  8, 1875,  be  here  reproduced 
in  part,  as  they  are  in  the  volume  before  us.  Mr.  Browne  maintains 
thai: — 

"1.  Attempts  at  removal  of  growths  from  within  the  larynx  are  not  in  them- 
selves so  innocuous  as  is  generally  believed,  but,  on  the  contrary,  direct  injury  of 
healthy  parts  of  the  larynx,  leading  to  fatal  results,  is  by  no  means  of  unfrequent 
occurrence. 

"2.  The  functional  symptoms  occasioned  by  benign  growths  in  the  larynx  are, 


4G4 


Reviews. 


[Oct. 


in  a  large  proportion  of  cases,  not  sufficiently  grave  to  -warrant  instrumental  inter- 
ference. 

"  3.  Many  of  these  new  formations  will  disappear,  or  be  reduced  by  appropriate 
local  and  constitutional  medical  treatment,  especially  when  of  recent  occurrence. 

"4.  Recurrence  of  laryngeal  growths,  after  removal  per  vias  natvrales,  is  much 
more  frequent  than  is  generally  supposed. 

"  5.  AVhile  primary  malignant  or  cancerous  growths  are  of  rare  occurrence 
within  the  larynx  itself,  benign  growths  not  unfrequently  assume  a  malignant, 
and  even  cancerous  character  by  the  irritation  produced  by  attempts  at  removal. 

"6.  The  instruments  most  generally  in  use  are  far  more  dangerous  than  those 
formerly  employed. 

"7.  The  cardinal  law,  that  'an  extra-laryngeal  method  ought  never  to  be 
adopted  unless  there  be  danger  to  life  from  suffocation  or  dysphagia.'  should  be 
applied  with  equal  force  to  intra-laryngeal  operations ;  and  it  is  a  subject  worthv 
of  consideration  whether,  in  many  cases,  tracheotomy  alone  might  not  be  more 
frequently  performed  :  a.  with  a  view  of  placing  the  patient  in  safety  when  dan- 
gerous symptoms  are  present;  by  in  order  that  the  larynx  may  have  complete 
functional  rest ;  and,  c,  as  a  preliminary  to  further  treatment,  radical  or  pal- 
liative." 

These  several  propositions  are  then  argued  in  detail,  with  what  success 
as  to  proving  the  writer's  case  the  reader  must  judge ;  they  are,  many  of 
them,  as  we  have  said,  novel — perhaps  somewhat  radical — but,  we  must 
admit,  are  likewise,  in  many  respects,  unquestionably  true,  and  at  least 
deserve,  from  their  very  importance,  careful  thought. 

The  question  as  to  the  advisability  of  operative  measures  in  cancer  of 
the  throat  (Chapter  XV.)  is  always  sure  to  be  pressed  upon  the  notice  of 
the  surgeon,  since  both  the  patient  and  his  friends  are  naturally  anxious 
that  the  obstruction  to  deglutition  should  be  removed,  and  that  the  life- 
threatening  dyspnoea  should  be  relieved.  Mr.  Browne  believes  and  states 
"that  there  can  be  no  objection  to  operative  procedures,  provided  it  be 
well  understood  on  both  sides  that  the  relief,  though  it  may  be  consider- 
able, is  but  temporary,  and  that  the  inevitable  termination  can  only  be 
postponed."  And  upon  the  question  of  a  tracheotomy  quotes  Fauvel's 
figures  as  demonstrating  "the  utility,  not  to  say  necessity,  of  this  opera- 
tion," asserting,  himself,  that  it  is  attended  with  very  considerable  pro- 
longation of  life — a  view  about  the  truth  of  which  there  can  be  no  difference 
of  opinion. 

The  interesting  question  of  entire  extirpation  of  the  larynx  is  summarily 
dismissed  in  the  following  words  :  "As  to  removal  of  the  larynx  entire  on 
account  of  cancer,  it  is  sufficient  to  point  out  that  no  case  yet  reported  has 
lived  more  than  six  months,  while  the  majority  have  been  immediatelv 
fatal." 

The  description  of  the  symptoms,  laryngoscopic  appearances,  prognosis, 
and  treatment  of  the  various  neuroses  of  the  larynx,  contained  in  Chapter 
XVI.,  is  concise,  yet  at  the  same  time  embraces  all  that  is  really  essential 
to  know  in  order  to  diagnose  and  treat  a  case  successfully.  It  will  be 
found  of  value  for  reference,  and  treating  as  it  does  of  one  of  the,  if  not 
the,  in  many  respects,  most  obscure  department  of  laryngeal  pathology, 
will  be  read  with  much  interest.  Frequent  reference  is  made  throughout 
it  to  the  labours  of  Mackenzie  and  Ziemssen  (the  name  of  Gerhardt  might 
have  been  added)  in  this  particular  field,  and  due  credit  is  given  them  for 
the  valuable  additions  that  they  have  made  to  our  knowledge.  Browne  in 
his  essay  upon  the  same  subject  has  contributed  nothing  new,  but  he  has 
given  us  an  excellent  and  convenient  resume.  As  we  glance  over  it  we 
learn,  under  the  head  of  laryngeal  hyperesthesia,  that  neuralgia  of  the 


1878.] 


Browne,  The  Throat  and  its  Diseases. 


465 


larynx  "  is  an  affection  which  has  received  but  little  attention  from  laryn- 
gologists,  and,  in  the  true  sense  of  the  term,  is  rare ;  since,  although  pa- 
tients not  unfrequently  complain  of  pain  in  the  larynx  as  their  only  symp- 
tom, it  is  seldom  that  objective  causes  cannot  be  .found.  Of  these  the 
more  frequent  are  general  anaemia,  and  especially  gouto-rheumatic  exacer- 
bations ;  patients  who  suffer  from  laryngeal  neuralgia  being  almost  always 
subject  to  similar  affections  of  the  fifth  and  of  the  sciatic  nerves." 

Neuroses  of  motion  he  divides,  according  to  Ziemssen,  into  paralyses 
of  motion  in  the  domain  of  the  superior  laryngeal  nerve  and  those  in  the 
domain  of  the  inferior  or  recurrent  laryngeal  nerve.  We  agree  with  the 
author  that  this  classification,  which  is  new,  is  well  worthy  of  adoption. 
Speaking  under  the  latter  head,  he  does  not  coincide  with  Mackenzie  in 
the  belief  that  bilateral  paralysis  of  the  adductor  muscles  of  the  larynx 
"  far  less  commonly  occurs  in  connection  with  amenorrhea  than  might  be 
supposed  from  the  writings  of  some  authors  ;"  but  says  that  "  in  point  of 
fact  amenorrhea  or  dysmenorrhea  is  the  more  frequently  coexistent  uterine 
condition ;  and  the  most  favourable  periods  of  life  for  its  occurrence  in  females 
are  at  the  commencement  and  on  cessation  of  menstruation."  And  again 
that  "  functional  aphonia  is  much  less  frequently  purely  hysterical  than 
is  generally  considered,  and  the  term  1  hysterical  loss  of  voice'  but  too  fre- 
quently represents  a  want  of  inclination  or  ability  to  find  out  the  true  cause" 
— a  remark  that  is  undoubtedly  true,  and  the  author's  plain  statement  of 
the  fact  will  meet  with  the  approbation  of  all  careful  laryngoscopies,  and 
offers  food  for  thought  to  the  old-time  general  practitioner.  We  remark, 
likewise,  that  there  exists  a  difference  of  opinion  between  Mackenzie  and 
other  writers  in  regard  to  the  appropriate  treatment  for  bilateral  paralysis 
of  the  abductor  muscles  of  the  larynx,  a  most  serious  and  even  dangerous 
condition.  All  laryngoscopists  are  agreed,  we  believe,  upon  the  necessity 
of  a  tracheotomy  in  these  cases  as  a  means  of  relieving  the  distress  of  the 
patient  and  prolonging  his  life;  but  the  former  authority  considers  "elec- 
trical treatment  scarcely  a  safe  procedure."  Mr.  Browne  pertinently  states, 
on  the  other  hand,  that  in  the  only  recorded  instance  in  which  decided 
improvement  took  place  (Ziemssen),  the  benefit  was  entirely  due  to  the 
alternate  applications  of  the  induced  and  constant  currents,  and  that  in  the 
cases  of  Gerhardt  and  Duranty,  the  same  treatment,  although  followed  by 
no  benefit,  was  equally  unattended  by  any  injurious  result. 

The  discussion  of  the  subject  of  differential  diagnosis,  with  a  table  of 
laryngeal  diseases,  in  which  symptoms,  both  functional  and  physical,  are 
contrasted,  constitutes  the  last  chapter  of  the  volume  before  us. 

We  have,  at  the  beginning  of  this  review,  recorded  our  personal  opinion 
of  the  merits  of  Mr.  Browne's  book,  and  have  aimed  throughout  to  present 
to  our  readers  such  selections  as  would  enable  them  to  judge  intelligently 
for  themselves  whether  or  no  our  opinion  was  justified.  Our  task  now 
finished  would,  however,  be  incomplete,  did  we  not  draw  special  atten- 
tion to  the  profusion  of  admirable  plates  which  accompany,  and,  we  must 
add,  adorn  the  text,  and  which,  from  an  artistic  point  of  view,  are  incom- 
parably the  best  that  we  have  seen,  if  we  except  the  well-known  atlas  of 
Tiirck.  The  illustrations  of  pharyngeal  conditions  specially  are  unique. 
The  author  tells  us  that  all  the  drawings  have  been  taken  from  nature,  and 
placed  on  stone  by  himself.  Two  plates  of  the  larynx  are  photographs  in 
autotype  of  his  original  drawings,  and  all  are  arranged  with  special  regard 
to  more  convenient  reference  than  is  usually  possible  during  study  of  any 
portion  of  the  text.  They  can  be  opened  out  so  as  to  lie  beside  the  page 
No.  CLII  Oct.  1878.  30 


466 


Reviews. 


[Oct. 


descriptive  of  the  disease  each  drawing  delineates.  Finally  we  confess  to 
being  sufficient  of  a  bibliomaniac  to  appreciate  most  thoroughly  the  taste- 
ful form  in  which  the  book  has  been  issued  by  its  publishers.  Good,  even 
elegant  binding,  thick  and  softly-tinted  paper,  broad  margins,  large  clear 
type,  and  fine  plates,  can  but  excite  pleasure  in  the  heart  of  the  lover  of 
books,  and  he  hails  the  appearance  of  each  new  medical  work  in  similar 
dress  with  satisfaction,  as  an  index  of  the  progress  that  is  being  made  in 
the  book-maker's  art  in  our  class  of  literature,  and  as  an  evidence  that  the 
homely  sheep-bound  book  of  our  forefathers  is  happily  obsolete. 

G.  M.  L. 


Art.  XVIII  Daltonism  or  Colour-blindness. 

1.  Dangers  from  Colour-blindness  in  Railroad  Employes  and  Pilots. 

By  B.  Joy  Jeffries,  M.D.,  Ophthalmic  Surgeon  Massachusetts 
Charitable  Eye  and  Ear  Infirmary.  [Extracted  from  the  Report 
of  the  Massachusetts  State  Board  "of  Health,  1878.]  8vo.  pp.  40. 
Boston,  1878. 

2.  Incurability  of  Congenital  Colour-blindness.    By  B.  Joy  Jeffries, 

M.D.    Boston  Med.  and  Surg.  Journal,  March  28,  1878. 

3.  Le  Daltonisme.    MM.  J.  Delboeuf  et  TV.  Spring,  Professeurs 

a  PUniversite  de  Liege.  Bevue  Scientifque  de  la  France  et  de 
VEtranger,  23  Mars,  1878. 

Of  a  large  number  of  publications  on  the  subject  of  colour-blindness, 
which  have  given  it  quite  an  extensive  literature,  those  whose  titles  head 
this  article  are  the  latest  that  have  come  to  our  notice. 

It  is  a  subject  of  much  interest  from  various  points  of  view.  As  M. 
Delboeuf  well  says,  "  It  belongs  to  physiology  as  well  as  to  physics,  to 
aesthetics  as  well  as  to  psychology ;  nor  is  it  a  stranger  to  philology  and 
history."  Added  to  these,  or  perhaps  rather  including  them  all,  it  has 
recently  claimed  a  place  in  the  theory  of  evolution. 

Without  undertaking  to  advocate  or  to  question  the  "  Young-Helm- 
holtz  theory,"  it  will  be  convenient  to  use  it  in  attempting  to  state  what 
is  meant  by  colour-blindness.  Taking  it  for  granted  that  the  three  base 
colours,  red,  green,  and  violet,  when  combined  in  various  proportions,  form 
the  solar  spectrum  as  seen  by  normal  eyes,  colour-blindness  may  be  said 
to  be  the  more  or  less  complete  inability  to  perceive  one  or  more  of  these 
colours.  As  each  of  these  colours  enters  into  the  composition  of  all  the 
colours  of  the  spectrum,  it  will  be  seen  how  complicated  the  result  of  this 
defect  must  be,  and  what  a  difficult  thing  it  is  to  find  out  with  any  degree 
of  precision  just  what  the  patient  does  see.  No  part  of  the  spectrum  is 
to  him  exactly  what  it  is  to  a  person  with  normal  vision,  and  his  nomen- 
clature is,  of  course,  at  fault ;  he  is  "  obliged  to  make  use  of  a  dictionary 
which  has  not  been  made  for  him."  Of  the  missing  colour  itself  he  has 
no  conception,  and  a  person  completely  red-blind,  however  brilliant  or 
learned  he  may  be,  can  hardly  be  said  to  know  what  he  is  talking  about 
when  he  speaks  of  red. 

Very  much  the  most  frequent  form  of  colour-blindness  is  that  for  red ; 
that  for  green  is  next  in  frequency ;  that  for  blue  is  rare  ;  while  cases  are 
on  record  of  persons  with  otherwise  normal  vision  who  were  blind  for  two 


1878.] 


Daltonism  or  Colour-blindness. 


467 


of  the  base  colours,  or  even  for  all  colour.  Even  when  one  colour  only  is 
involved,  the  defect  may  vary  indefinitely  in  degree  ;  indeed,  M.  Delboeuf 
inclines  to  the  opinion  that  no  two  people  see  colours  exactly  alike,  that 
each  one  has,  as  it  were,  a  spectrum  of  his  own.  The  defect  may  be 
shown  merely  by  the  demand  for  a  greater  intensity  of  illumination  for 
the  recognition  of  a  colour.  We  have  met  recently  with  a  gentleman  who 
could  see  only  a  uniform  green  in  a  cherry  tree  at  the  foot  of  his  lawn, 
which  to  others  was  "in  a  blaze  of  red,"  with  a  profusion  of  fruit,  while 
he  had  no  difficulty  in  recognizing  the  red  colour  of  a  bed  of  geraniums 
near  the  house.  • 

Colour-blindness  is  much  more  frequent  than  is  usually  supposed.  Dr. 
Wilson,  of  Edinburgh,  in  the  examination  of  1154  persons,  found  5.6  per 
cent,  colour-blind.  Prof.  Helmholtz  admits  this  proportion ;  and  Dr. 
Jeffries,  among  611  students  of  Harvard  University  and  the  Boston  In- 
stitute of  Technology,  found  colour-blindness  in  five  per  cent.  It  is 
believed  to  be  much  less  frequent  in  females  than  in  males.  The  sub- 
ject of  colour-blindness  is  frequently  quite  unconscious  of  the  defect; 
indeed,  when  it  does  not  exist  in  a  high  degree,  this  is  said  to  be  the  rule. 

The  following  resume  of  the  observations  of  Holmgren  on  this  subject  is 
translated  from  the  paper  of  Delboeuf : — 

"  It  would  seem  that  those  affected  should  be  easily  detected.  Experience, 
however,  proves  the  contrary.  The  author  has  examined  the  whole  personnel  of 
a  railroad  line,  and  found  that  a  large  number  of  the  employes,  though  obliged  to 
give  attention  by  day  and  night  to  signal  colours,  had  a  defective  sense  without 
cither  themselves  or  others  having  ever  suspected  it.  Here  is  the  explanation  of 
this  strange  fact. 

"  Our  senses  are  directed  to  the  cognizance  of  the  exterior  world  in  a  manner 
entirely  practical.  Hence  it  results  that  objects  are  invested  by  us,  and  that  per- 
manently, with  qualities  that  are,  at  bottom,  but  our  peculiar  ways  of  perceiving. 
It  is  thus  that  a  red  carpet  is  for  us  constantly  a  red  carpet,  even  in  darkness, 
even  when  we  are  not  looking  at  it.  If  then  we  say  to  a  child,  this  carpet  is  red, 
he  will  retain  the  name,  and  will  apply  it  correctly  every  time  that  he  sees  the 
carpet.  Xow,  in  fact,  it  is  not  only  by  the  colour  that  he  recognizes  it,  but  by  a 
complex  combination  of  qualities,  among  which  the  sensation  of  colour  plays  but 
a  secondary  role.  If  his  colour-vision  is  defective  or  not,  the  child  will  learn  in 
this  manner  that  the  sky  is  blue,  grass  green,  bricks  red,  and  even  if  it  may  hap- 
pen  that,  to  his  eyes,  bricks  have  the  same  colour  as  grass,  it  will  never  occur  to 
him  to  confuse  these  objects  and  to  attribute  to  one  of  them  a  quality  that  does 
not  belong  to  it. 

"Doubtless  Daltonians  have  no  comprehension  of  certain  distinctions  estab- 
lished by  others  ;  but,  after  more  or  less  fruitless  efforts,  the  greater  number  say 
to  themselves  that  colours  offer  little  problems  that  they  are  not  called  upon  to 
resolve,  and  think  no  more  of  it.  But  others  go  further;  they  persist  in  finding 
out  the  distinctive  character  of  the  colours  which  they  confound ;  they  see  in  it  a 
matter  of  dimness  and  intensity  of  light,  acquire  a  great  skill  in  distinguishing 
them  by  this  means,  and  end  by  deceiving  themselves. 

"  There  are  nevertheless  circumstances  in  which  it  would  seem  that  the  person 
must  necessarily  discover  his  own  defect.  It  is  when  he  must  determine  his 
actions  by  the  colours  of  objects.  This  is  the  case  with  painters,  tailors,  and  the 
employes  of  the  marine  and  railroads.  Even  here,  however,  a  multitude  of 
causes  concur  to  hide  from  them  continually  the  anomaly  of  their  visual  sense. 
In  the  rural  districts,  among  the  lower  classes,  little  attention  is  paid  to  the  colour 
of  objects.  If  a  bucket  or  a  piece  of  furniture  is  to  be  painted,  all  that  is  required 
is  that  it  shall  be  painted,  and  that  the  colour  shall  be  bright ;  it  matters  little 
whether  it  is  red  or  green  or  brown.  If  a  garment  is  to  be  mended,  the  essential 
is  that  the  rent  shall  be  closed,  and  it  is  considered  a  secondary  matter  whether 
the  patch  shall  be  of  the  same  colour  as  the  rest.  The  engineer  who  directs  the 
locomotive  is,  in  the  first  place,  never  alone ;  then,  as  he  knows  at  what  places 


4G8 


Reviews. 


[Oct. 


the  signals  are  generally  made,  he  looks  for  them  and  learns  to  recognize  them 
by  the  particular  intensity  of  their  light ;  he  has  thus  no  reason  to  suspect  his 
defect.  All  the  colour-blind  on  the  railroads  that  Holmgren  had  occasion  to  in- 
spect persisted  in  affirming  that  they  had  excellent  vision  ;  that  they  distinguished 
the  signals  without  difficulty  ;  and  that  they  had  never  committed  a  blunder." 

Attention  was  first  called  to  imperfections  in  the  colour  sense  in  1777 
by  Joseph  Huddart's  brief  description  of  the  cases  of  brothers  named 
Harris.  The  subject  never  received  scientific  investigation  until  the 
famous  English  chemist,  Dalton,  who  was  red-blind,  described  his  own 
case  in  1794.  He  was  persuaded  that  his  vitreous  humour  must  be  blue, 
and  directed  that  it  should  be  examined  after  his  death. 

The  term  "  Daltonism"  has  been  for  many  years  almost  universally 
applied  to  colour-blindness ;  but,  according  to  Dr.  Jeffries,  "  It  is  now, 
however,  generally  agreed  to  give  up  this  use  of  so  distinguished  a  man's 
name,  and,  as  has  been  claimed,  'Daltonism'  should  mean  rather  the  doc- 
trine of  indivisible  chemical  atoms,  and  '  Daltonian'  a  believer  in  such." 
Chromatopseudopsie,  achromatopsie,  and  a  number  of  other  hard  names 
have  been  proposed,  but,  as  they  do  not  express  the  affection  more  defi- 
nitely than  "  colour-blindness,"  it  seems  scarcely  desirable  to  burden  the 
literature  of  the  subject  with  them. 

Dr.  Isaac  Hays  published  a  paper  on  the  "  Impossibility  of  Distinguish- 
ing Colours,"  in  the  American  Journal  of  the  Medical  Sciences  for  Au- 
gust, 1840,  and  was,  we  believe,  the  first  to  call  special  attention  to  the 
defect  as  a  pathological  condition;  and  in  1845  Dr.  Pliny  Earle,  in  the 
same  Journal,  reported  the  singular  history  of  the  colour-blindness  of 
five  generations  of  his  own  family.  Comparatively  little  attention,  how- 
ever, has  been  given  to  the  subject  in  this  country,  and  Dr.  Jeffries  has 
the  merit  of  being  the  first  on  this  side  of  the  Atlantic  to  urge  its  great 
practical  importance,  especially  in  our  railway  and  marine  service. 

It  is  hardly  necessary  to  refer  to  the  fact,  so  well  known  to  the  travel- 
ling public,  that  the  use  of  red  and  green  signals  is  universal  both  on  land 
and  sea,  and  that,  particularly  at  night,  the  proper  interpretation  of  these 
signals  is  absolutely  the  only  security  against  collisions  and  other  acci- 
dents. Another  fact,  not  so  generally  known,  but  equally  evident  to  those 
who  have  given  their  attention  to  the  subject,  is  that  there  are,  in  every 
community,  a  considerable  number  of  persons  who  coimot  distinguish 
between  red  and  green.  One  would  suppose  that  the  eloquence  of  these 
two  facts,  considered  together,  would  be  enough  to  convince  any  reason- 
able mind  of  the  necessity  of  taking  the  strictest  precautions  to  exclude 
such  persons  from  positions  where  their  defect  must  involve  such  very 
grave  dangers.  This  reform,  however,  has  had  to  contend  not  only  against 
considerations  of  trouble  and  expense  and  the  sacrifice  of  the  interests  of 
the  few  to  those  of  the  many,  but  against  the  honest  incredulity  of  those 
in  authority,  whose  practical  experience  has  seemed  to  justify  their  doubts. 

As  to  the  manner  in  which  colour-blindness  may  be  concealed  even  from 
the  knowledge  of  the  person  affected,  and  the  fact  that  railroad  employes  and 
others  may  learn  to  recognize  a  signal  by  the  intensity  of  its  light  without 
being  able  to  distinguish  its  colour,  we  have  already  quoted  the  explana- 
tion of  Prof.  Holmgren,  of  Sweden,  who  has  been  more  persistent  and 
successful  than  any  one  else  in  urging  the  importance  of  this  matter. 
The  following  practical  application  of  this  explanation,  by  the  same 
authority,  is  taken  from  the  pamphlet  of  Dr.  Jeffries : — 

"Did  we  not  know  this  we  should  be  greatly  astonished  to  find  with  what 
facility  a  colour-Mind  railroad  employe  can  distinguish  between  the  red  and  green 


1878.] 


Daltonism  or  Colour-blindness. 


469 


flag,  and  generally  call  the  red,  green,  and  yellow  lanterns  by  their  right  colour ; 
but  it  is  the  intensity  of  the  light,  and  not  the  colour,  which  governs  his  decision, 
and  this  is  (he  whole  secret.  The  flags  and  lanterns  have,  in  fact,  usually  a  con- 
stant difference  as  to  intensity.  The  green  flag  is  to  the  colour-blind,  as  also  to 
the  normal  eye,  undoubtedly  of  the  deepest  or  darkest  colour,  and  the  red  the 
most  brilliant.  As  to  the  lanterns  the  red-blind  always  recognize  the  red  light 
by  its  being  darker  than  the  green,  and  the  yellow  by  its  being  clearer  or  more 
brilliant  than  the  other  two.  The  green-blind  finds  also,  in  his  turn,  the  red 
more  brilliant  than  the  green,  and  distinguishes  it  by  this  

"  Considering  only  practically  the  fact  mentioned,  and  the  explanation  we  have 
•riven,  we  might,  perhaps,  imagine  that  colour-blindness  had  some  scientific,  but 
Hardly  any  practical  interest,  and  hence  that  all  the  talk  that  has  been  made 
about  it  in  railroad  employes  in  our  country  was  unnecessary,  because,  as  may  be 
said,  the  colour-blind  have  often  been  employed  for  along  time  in  railroad  service 
without  its  being  noticed,  and  without  accident  or  the  slightest  inconvenience 
arising  :  and.  finally,  that  since  they  can  really  distinguish  the  signals  (although 
this  is  otherwise  than  by  colour)  their  kind  of  blindness  need  not  call  for  any  pre- 
ventive measures.  It  is  thus  that  a  great  many  persons  still  reason.  We  do  not 
stop  here  to  give  the  testimony  of  experience  on  this  point  in  our  country.  One 
fact  is  certain :  namely,  that  colour-blindness  in  other  countries  has  caused 
numerous  and  very  fatal  accidents  

"  That  the  situation  of  the  colour-blind  in  respect  to  signals  maybe  thoroughly 
understood,  we  must  here  add  a  few  important  words  on  this  point.  What  is  the 
intensity  of  light  ?  Strictly  speaking  it"  is  nothing  but  the  force  of  the  impres- 
sion of  the  light  which  our  eye  receives.  This,  however,  is  dependent  on  two 
factors :  one,  the  quantity  of  light  radiating  from  the  object  observed  or  reflected 
from  it ;  the  other,  the  strength  or  amount  to  which  the  eye  reacts  to  this,  or,  in 
other  words,  the  sensibility  of  the  subjected  visual  sense.  We  may  readily  un- 
derstand that  both  of  these  factors  are  extremely  variable  under  the  circumstances 
of  the  engineer's  service.  The  amount  of  light  which  comes  to  his  eye  depends 
naturally  on  the  amount  reflected  from  a  coloured  object,  or  which,  for  example, 
radiates  from  a  railroad  lantern.  It  is  very  evident  that  this  quantity  may  vary 
from  many  causes,  such  as  the  nature,  of  the  illuminating  material,  and  the  wick, 
the  colouring  matter  of  the  glass,  its  thickness,  the  peculiar  property  of  the  glass, 
etc.  If  a  little  moisture  or  smoke,  vapour,  ice,  snow,  etc.,  adheres  to  the  glass 
the  lantern  is  less  luminous.  A  lantern  illuminates  more  in  clear  than  in  foggy 
weather.  All  this  may  give  rise  to  mistakes.  But,  on  the  other  hand,  the  sen- 
sibility of  the  eye  differs  greatly  under  different  circumstances.  The  nervous 
apparatus  of  the  eye  may,  like  all  other  parts  of  the  system,  vary  in  its  sensitive- 
ness. The  same  light  is  brighter  to  a  healthy  eye  in  repose  than  to  an  eye 
fatigued  and  weakened.  Every  modification  of  the  intensity  of  the  light  is, 
however,  for  the  colour-blind  a  change  in  colour.  .  .  .  Ask  any  superior  official 
of  a  road  if  he  would  be  willing  to  take  charge  of  and  run  a  locomotive,  assum- 
ing the  responsibility,  when  uncoloured  signals  alone  were  permitted,  and  a  feeble 
light  meant  danger,  a  medium  one  caution,  and  a  strong  one  road  clear.  If  he 
says  no,  tell  him  that  these  are  just  the  conditions  under  which  every  colour-blind 
engineer  has  performed  his  duties.    The  absurdity  is  evident  at  once." 

In  a  communication  to  the  Chicago  Raihuay  Revieiv,  on  "  Defective 
Vision  considered  in  its  relation  to  Railroad  Management,"  Mr.  Thomas 
F.  Wilson  says  that  he  has  kept  record  of  accidents  by  land  and  water  for 
some  years,  and  gathered  all  the  information  he  could  in  reference  to  them, 
and  is  convinced  that  a  large  proportion  of  them,  were  the  results  of  colour- 
blindness. The  comparatively  small  number  of  accidents  from  this  cause 
he  attributes  to  the  "  high  average  intelligence  and  acquired  cautiousness 
of  engineers  and  pilots  as  a  class,"  and  says  they  acquire  a  "  sort  ot 
instinct"  that  guides  them.  He  tells  of  an  engineer  who  was  continually 
making  narrow  escapes,  until  colour-blindness  was  finally  proved  and 
acknowledged.    This  man  afterwards  declared  that  he  had  had  nothing 


470 


Reviews. 


[Oct. 


definite  to  base  his  actions  upon,  but  had  been  guided  entirely  by  this  cau- 
tion and  instinct. 

The  testing  for  colour-blindness  is  by  no  means  so  simple  a  matter  as  it 
might  at  first  sight  appear.  It  would  be  quite  useless,  for  instance,  to  test 
an  engineer  with  the  flags  and  lanterns  with  which  he  has  become  familiar. 
Any  test  necessitating  the  naming  of  a  colour  is  imperfect ;  a  person  may 
name  the  colour  of  an  object  correctly  because  he  has  heard  that  name  ap- 
plied to  it,  or  has  associated  the  name  with  some  other  quality  of  the 
object,  though  he  has  no  conception  of  its  colour. 

Even  the  congenitally  blind  can  usually  give  correctly  the  colour  of  the 
sky  or  of  foliage.  A  person  interested  to  conceal  his  defect  might  even 
intentionally  deceive  by  making  ingenious  guesses  founded  on  the  intensity 
of  the  reflected  light,  or  upon  some  other  properties  of  the  object.  An 
amusing  instance  of  the  latter  is  related  by  Mr.  Chapin,  principal  of  the 
Pennsylvania  Institution  for  the  Blind.  One  of  his  former  pupils,  who 
was  stone  blind,  asserted  in  the  presence  of  a  number  of  gentlemen  that 
he  could  distinguish  colour  by  the  touch.  When  challenged  to  the  proof, 
he  passed  his  hand  down  the  front  of  their  coats  and  pronounced  one  blue, 
another  black,  and  another  gray  ;  in  each  case  correctly.  The  first  coat 
had  metal  buttons,  the  second  was  of  close  texture  and  smooth  surface 
and  had  covered  buttons,  and  the  third  he  recognized,  from  the  cut  of  the 
collar,  to  be  the  coat  of  a  Quaker. 

A  number  of  different  tests  have  been  proposed ;  the  simplest  and  best 
is  that  used  more  than  twenty  years  ago  by  Wilson,  of  Edinburgh,  and 
recently  revived  by  Holmgren.  The  person  examined  is  directed  to  match 
different  coloured  worsteds.    It  is  now  very  generally  adopted  in  Europe. 

As  to  the  practical  results  of  the  agitation  of  this  subject,  Dr.  Jeffries 
informs  us  that  the  Swedish,  Russian,  and  Bavarian  governments  have 
ordered  all  persons  connected  with  the  railroads  to  be  tested  for  colour- 
blindness ;  in  Italy  all  railroad  employes  are  subjected  to  rigorous  exami- 
nations; and  investigations  have  been,  or  are  being  made,  on  an  extensive 
scale,  in  France,  Belgium,  Holland,  Denmark,  and  Finland.  In  Finland, 
of  1200  employes  examined,  GO  were  found  colour-blind.  Not  much  pro- 
gress has  been  made  in  England,  though  Prof.  Tyndall  has  added  his 
warning  to  that  given  strongly  twenty  years  ago  by  Wilson ;  but  the  sub- 
ject is  being  discussed  there. 

In  this  country,  so  far  as  we  know,  absolutely  nothing  has  as  yet  been 
done.  It  is  to  be  hoped  that  Dr.  Jeffries's  pamphlet  may  direct  the  atten- 
tion of  those  in  authority  to  the  very  great  importance  of  this  subject. 

The  article  on  "  Incurability  of  Congenital  Colour-blindness,'  is  a 
criticism  on  the  views  of  Dr.  Favre,  of  Lyons,  who  has  been  the  only 
authority  to  advocate  the  possibility  of  curing  it  by  systematic  exercise  of 
the  eye  with  colours.  It  is  shown  that  Dr.  Favre  has  confused  the  know- 
ledge of  the  name  of  a  colour  with  the  ability  to  perceive  the  colour.  The 
author  is  confident  that  a  colour-blind  person  can  no  more  be  taught  to 
recognize  the  colour  in  which  his  spectrum  is  deficient  than  he  can  be 
taught  to  hear  a  note  above  or  below  the  vibratory  scale  of  his  ear. 

Those  who  desire  to  study  the  subject  of  colour-blindness  will  be  thank- 
ful to  Dr.  Jeffries  for  the  very  copious  and  complete  bibliography  that 
he  has  furnished. 

Delboeuf  is  himself  a  "  Daltonian,"  and,  in  endeavouring  to  verify  the 
Young-Helmholtz  theory,  it  occurred  to  him  that  it  might  be  possible  that 
the  atrophy  of  the  red-perceiving  elements  was  only  relative,  in  the  sense 


1878.] 


Daltonism  or  Colour-blindness, 


471 


that  their  action  was  masked  by  the  preponderating  action  of  the  two  other 
elements.  Supposing  this  to  be  the  case,  it  would  follow  that  by  inter- 
posing between  the  eye  and  external  objects  a  transparent  reddish  sub- 
stance he  could  "re-establish  the  equilibrium,"  since,  in  this  way,  the  green 
and  violet  rays  would  be  in  part  extinguished. 

One  of  the  greatest  difficulties  in  the  way  seemed  to  be  to  determine  the 
exact  degree  of  coloration  to  be  used,  and,  to  overcome  this,  he  decided 
upon  a  coloured  liquid  inclosed  in  a  glass  prism.  This  gave  a  degree  ot 
colour  increasing  gradually  from  angle  to  base.  The  colouring  matter 
selected  was  a  solution  of  fuchsin  (magenta).  The  effect  of  looking  through 
this,  the  author  assures  us,  was  marvellous.  Not  only  did  the  colours  which 
he  habitually  confounded — blue,  carmine,  and  violet  on  the  one  side,  and 
scarlet  and  brown  on  the  other — appear  decidedly  different,  but  scarlet  par- 
ticularly assumed  a  brightness  before  unknown  to  him  ;  while  before  it  had 
appeared  dull,  it  now  became  brilliant  (-'flamboyant  et  eblouissant").  The 
experience  of  a  number  of  other  Daltonians,  upon  whom  he  experimented, 
was  the  same. 

The  author  claims  that  these  experiments,  if  they  do  not  entirely  subvert 
the  Young-llelmholtz  theory,  at  least  prove  that  the  colour-blind  owe  their 
peculiarities  of  vision  not  to  an  atrophy,  more,  or  less  complete,  of  the  red- 
perceiving  elements,  but  rather  to  a  special  susceptibility  to  the  green  and 
violet  rays,  or,  more  exactly,  to  the  colour  complementary  to  fuchsin. 

It  would  seem,  at  first  thought,  that  any  red  substance  should  produce 
the  same  effect  as  fuchsin,  and  that  this  effect  could  not  be  produced  by  any 
substance  of  another  colour ;  but  this  was  found  not  to  be  the  case.  Ani- 
line violet,  and  cosine,  which  is  orange,  also  corrected  his  Daltonism, 
though  in  a  less  degree  ;  while  a  piece  of  glass,  coloured  red  by  oxide  ot 
copper,  produced  no  other  effect  than  to  deaden  all  the  colours  except  red. 

This  proved  that  the  correction-property  of  the  fuchsin  was  not  depen- 
dent upon  its  colour ;  and  when  this  substance  was  analyzed  by  the  spec- 
troscope, it  was  found  that  it  extinguished  the  green  region  of  the  spectrum, 
and  it  only.  The  dark  band  was  sharply  defined,  particularly  on  the  side 
next  the  yellow. 

Spectroscopic  analysis  of  aniline  violet  and  of  eosine  gave  the  same 
result,  except  that  the  dark  band  was  less  sharply  defined,  and  its  position 
was  somewhat  different.  But  the  glass  coloured  with  oxide  of  copper 
obliterated  all  the  colours  except  the  red. 

The  author  thinks  that  if  he  has  not  completely  proved,  he  has  at  least 
made  it  probable,  that  it  is  the  presence  of  the  whole  or  a  part  of  the  green 
(which  may  be  suppressed  by  fuchsin)  that  renders  certain  eyes  insensible 
to  the  complementary  colours. 

The  next  step  was  to  attempt  to  produce  Daltonism  artificially  in  normal 
eyes  by  suppressing  or  enfeebling  all  the  light  but  the  green.  After  ex- 
perimenting with  a  number  of  substances  without  success,  chance  again 
came  to  the  rescue  and  threw  chlorate  of  nickel  in  his  way.  Through  a 
four  per  cent,  solution  of  this  substance,  M.  Spring,  whose  vision  is  normal, 
found  violet  to  become  blue,  red  to  identify  itself  with  brown,  and  nature 
to  assume  a  dull  and  uniform  aspect.  The  effect  of  this  solution  on  the  solar 
spectrum  was  to  reduce  it  to  a  green  band  corresponding  exactly  to  the 
gap  that  the  fuchsin  had  made  in  it. 

Daltonism,  produced  artificially  by  chlorate  of  nickel,  was  corrected  by 
fuchsin ;  and  natural  Daltonism,  corrected  by  fuchsin,  was  restored  by 
chlorate  of  nickel. 


472 


Reviews. 


[Oct. 


As  a  physiological  hypothesis,  the  author  suggests  the  application  to 
colour-vision  of  the  "  Theory  of  the  natural  equilibrium  of  the  organs  oi 
sense,"  which  he  has  advocated  elsewhere,  and  which  he  calls  the  "Psycho- 
physic  law." 

According  to  the  wave  theory  of  light,  the  different  colours  of  the  spec- 
trum depend  upon  the  different  rates  of  vibration  of  the  ethereal  waves. 
If  the  number  of  vibrations  for  green  be  represented  by  9,  blue,  indigo, 
and  violet  will  be  10,  11,  and  12;  and  red,  orange,  and  yellow  will  be  6, 
7,  and  8.  The  retina  is  compared  to  a  membrane  set  to  a  certain  tone,  but 
capable  of  being  stretched  or  relaxed  under  the  action  of  external  forces ; 
just  as  the  vocal  cords,  though  they  manifest  a  certain  preference  for  a 
special  octave,  can  vibrate  in  unison  with  octaves  above  or  below  it.  It 
the  natural  tension  of  the  retina  be  supposed  to  be  adapted  to  green,  the 
sensation  of  green  will  result  from  the  characteristic  vibration  of  the 
membrane. 

Designating  by  0  the  natural  equilibrium  of  the  retina  corresponding  to 
the  number  9,  which  represents  the  number  of  vibrations  for  green,  the 
series,  beginning  with  violet  and  ending  with  red,  may  be  expressed  by 
+  3  +  2  +  1.0.  —  1  —  2  —  3. 

"But,  like  all  elastic  substances,  the  retina  tends  to  maintain  itself  at  0;  it  is 
not  without  a  certain  resistance  that  it  takes  the  movements  +  1  and  —  1 ;  its 
repulsion  is  more  marked  for  the  movements  -f-  2  and  —  2 ;  and  much  more 
decided  still  for  the  movements  +  3  and  —  3.  Its  inertia  will  be,  in  each  case, 
reinforced  by  the  presence  of  green  rays  which  exist,  in  greater  or  less  quantities 
in  all  complex  colours.  For  the  moment  that  the  retina  feels  their  presence,  it 
will  obey  them,  and  its  capacity  to  obey  a  different  force  will  be  diminished  in 
proportion  as  the  effects  of  this  latter  force  are  in  part  masked  by  the  preponder- 
ating effects.  Nevertheless,  in  normal  vision  this  diminution  will  never  go  so 
far  as  to  prevent  the  retina  from  receiving,  or,  if  you  will,  from  perceiving  the 
extreme  movements.  But  with  Daltonians  this  is  not  the  case  ;  with  some,  it 
refuses  to  yield  itself  sufficiently  to  the  movements  +  3  and  —  3  ;  with  others, 
to  the  movements  +  2  and  —  2  ;  finally,  there  are,  perhaps,  some  where  it  will 
not  receive  even  the  movements  +  1  and  — 1.  Hence  we  can  readily  conceive 
why  these  Daltonians  are  corrected,  either  by  the  interposition  of  fuchsin,  which 
checks  the  auxiliary,  or  by  the  projection  of  purple  light,  which  brings  support 
to  the  insufficient  forces." 

This  theory  is  ingenious  and  entertaining,  but  fanciful,  and,  perhaps, 
somewhat  crude  ;  indeed,  the  author  himself  speaks  of  it  as  merely  a  rough 
sketch,  and  excuses  his  departure  from  what  he  says  might  be  a  becoming 
reserve  by  the  hope  that  his  theory,  even  if  false,  may  assist  in  directing 
others  in  the  right  path.  At  all  events,  he  is  on  debatable  ground  where 
any  one  may  build  a  theory,  and  hold  it  if  he  can. 

The  question  naturally  arises,  supposing  these  views  to  be  correct,  why 
"  Daltonians"  should  not  distinguish  the  green  of  the  spectrum.  The 
author  says  this  fact  is  analogous  to  the  well-known  phenomenon  that  arti- 
ficial light  (which  has  an  excess  of  yellow)  makes  yellow  objects  appear 
white  : — 

"Any  kind  of  light,  when  it  is  the  only  light,  tends  to  appear  white.  It  is 
thus  that  the  photograph  er,  in  his  chemical  cabinet,  which  is  lighted  only  by 
yellow  light,  does  not  see  it  yellow  but  white  ;  it  would  be  the  same  if  the  glass 
were  blue  or  red.  .  .  .  With  the  natural  Daltonian,  as  with  him  whose  eye  is 
submitted  to  general  excitation  by  green  light,  the  green  may  be  unperceived  or 
produce  the  effect  of  white  light." 

The  last  section  of  the  paper  relates  to  the  possibility  of  curing  Dalton- 
ism.   Of  this  our  author  is  by  no  means  hopeless.    He  tells  us  that,  after 


1878.] 


Daltonism  or  Colour-blindness. 


473 


having  spent  much  time,  during  several  months,  in  experimenting  with 
the  fuchsin,  he  noticed  a  decided  change  in  the  colouring  of  a  favourite 
picture.  Some  time  afterwards,  while  walking  in  the  street  at  night,  he 
distinguished  the  red  light  of  a  lantern  placed,  as  a  warning,  over  a  breach 
in  the  culvert ;  and  found  that  he  could  distinguish  the  red  colour  of  a 
railway  light  which,  lately,  had  not  appeared  to  him  different  from  an  ordi- 
nary gas  flame.  He  is  here,  again,  ready  with  a  theory,  or  rather  con- 
siders this  experience  a  confirmation  of  the  theory  already  proposed.  The 
fuchsin  overcomes  certain  resistances  by  arresting  the  rays  of  light  whose 
property  it  is  to  encourage  and  maintain  these  resistances,  and  he  had  sub- 
dued these  so  often  in  his  frequent  and  long-continued  use  of  the  fuchsin 
that  the  nervous  element  of  his  retina  had.  as  it  were,  acquired  new  habits 
and  yielded  more  readily  to  the  force  of  luminous  impulses. 

Delboeuf's  experiments  with  coloured  media  remind  one  of  Liebreich's 
London  lecture  on  Turner  and  Mulready.  Liebreich  took  the  ground  that 
the  excessive  blue  in  the  later  pictures  of  Mulready,  who  continued  to 
paint  after  he  was  seventy  years  of  age,  was  due  to  yellow  degeneration  of 
the  crystalline  lens  ;  and  maintained  that  this  excess  of  blue  could  be 
neutralized,  and  these  pictures  could  be  restored  to  the  harmony  of  the 
artist's  earlier  productions,  by  looking  at  them  through  a  glass  slightly 
tinted  with  yellow. 

The  observations  of  M.  Delboeuf  are  new  and  interesting,  and  will,  we 
believe,  prove  useful ;  for,  though  he  is  evidently  not  free  from  the  bias  of 
a  favourite  theory,  and  perhaps  avails  himself  rather  freely  of  the  "scien- 
tific use  of  the  imagination,"  he  has  worked  ably  and  honestly  and  with 
great  ingenuity  in  a  difficult  field  of  study,  and  his  labours  can  hardly  fail 
to,  at  least,  excite  renewed  interest  in  this  important  subject. 

It  is  one  of  those  subjects  which,  though  they  may  appear  simple 
enough  to  the  superficial  glance,  expand  indefinitely  as  you  penetrate 
them  more  deeply,  and  become  more  intricate  the  more  you  study  them. 
It  is  involved  in  the  wide  and  unsettled  subject  of  colour  vision,  concern- 
ing which  scientific  opinion  seems  to  be  just  now  in  a  state  of  transition, 
and  must  remain  in  doubt  so  long  as  does  the  latter.  We  must  have  a 
theory  of  colour-vision  before  we  can  have  one  of  colour-blindness. 

Those  who  have  the  strongest  faith  in  the  "  potency  and  promise  "  ot 
the  retinal  red,  discovered  by  Boll,  will  have  most  hope  of  the  final  settle- 
ment of  these  questions  on  a  photo-chemical  basis.  The  theory  that  all 
the  phenomena  of  visual  impressions  are  the  result  of  changes  effected  in 
this  colouring  matter  by  the  action  of  light  is  most  attractive,  and  may 
contain  the  germ  of  the  future  solution  of  the  whole  matter.  Its  present 
status,  however,  is  scarcely  more  than  suggestive. 

The  question  seems  even  more  complicated  when  we  remember  that  the 
sensation  of  light  and  the  sensation  of  colour  are  the  result  of  two  distinct 
functions.  In  some  observations  recently  communicated  to  the  French 
Academy  of  Sciences  by  MM.  Landalt  and  Charpentier,  it  was  shown 
that  "  the  luminous  sensation  is  the  reaction,  simple,  primitive,  essential, 
constant,  of  the  visual  apparatus;  the  sensation  of  colour  is  a  reaction, 
secondary,  inconstant,  variable,  according  to  the  point  of  the  retina  con- 
sidered, and  according  to  a  number  of  experimental  conditions."  The 
chromatic  sensibility  may  vary  independently  of  the  luminous,  and  the 
luminous  may  vary  under  certain  conditions,  while  the  chromatic  re- 
mains constant.  Indeed,  these  conclusions  do  little  more  than  formulate 
familiar  facts  of  every -day  experience ;  the  colour-blind  may  have  more 


474 


Reviews. 


[Oct. 


than  the  average  acuteness  of  vision  for  form,  and  we  not  unfrequently 
meet  with  persons  M  ho  have  not  vision  enough  to  go  about  alone,  but  who 
can  still  distinguish  colours. 

A  large  portion  of  the  retina  is  normally  colour-blind,  the  whole 
spectrum  is  seen  only  in  the  central  portion  around  the  macula  lutea ;  be- 
yond that  the  perception  of  red  disappears,  then  that  of  green,  and  finally, 
at  the  periphery,  the  sensibility  to  blue  only  remains.  According  to 
Dobrowolski,  the  limit  for  the  sensibility  for  red  is  80°  from  the  fovea, 
for  green  95°,  and  for  blue  10.jc.  the  extent  of  the  visual  field.  This  is 
on  the  inner  side  of  the  retina,  on  the  outer  side  the  limits  are  65°,  73°, 
and  77°.    These  conditions  are  frequently  modified  by  disease. 

According  to  Geiger,  Magnus,  and  others,  what  would  now  be  colour- 
blindness was  the  normal  condition  of  our  remote  ancestors ;  the  sensi- 
bility to  colours  enjoyed  by  the  present  generation  is  the  hereditary  result 
of  education  prolonged  through  many  generations  ;  in  other  words,  the 
colour  sense  has  been  developed  by  a  process  of  evolution.  This  theory, 
advanced  some  years  ago  by  Geiger,  who  has  since  died,  has  been  recently 
developed  at  considerable  length  by  Hugo  Magnus,  Professor  of  Ophthal- 
mology in  the  University  of  Breslau.  Magnus  divides  the  colours  of  the 
spectrum  into  three  classes  :  those  richest  in  light,  red,  orange,  and  yellow  ; 
that  which  has  a  medium  degree  of  luminosity,  green  ;  and  those  which 
are  feeblest  in  light,  violet,  indigo  and  blue  ;  and  argues  ingeniously  and 
learnedly  to  show  that  the  advancing  ages  acquired  each  in  turn.  He 
maintains  that  primitive  man  possessed  only  the  sense  of  light,  that  red  was 
the  first  and  violet  the  last  colour  to  be  recognized,  and  that  it  is  not  im- 
possible that  our  descendants  may  acquire  the  appreciation  of  colours  that 
escape  the  present  generation.  Geiger  stated  that  the  Rig- Veda  contained 
no  mention  of  green,  blue,  or  violet,  and  similar  statements  have  been 
made  of  the  Koran  and  the  Bible.  Magnus  says  that  Xenophen  saw  only 
three  colours,  red,  purple  and  greenish-yellow,  in  the  rainbow,  and  that 
the  Homeric  poems  belong  to  the  same  colour-period,  as  they  confound 
green  with  yellow.  The  mention  of  the  Homeric  age  brings  to  the  front 
Mr.  Gladstone,  who  fully  adopts  the  views  of  Magnus,  and  shows  that 
Homer  perceived  red  and  yellow,  but  confused  green  with  yellow  and  blue 
with  black. 

We  refer  to  this  theory,  as  briefly  as  possible,  merely  because  it  has 
been  extensively  discussed,  both  in  and  out  of  the  profession,  and  forms 
an  interesting,  if  not  very  important,  chapter  in  the  literature  of  our  sub- 
ject. The  objections  to  it  are  numerous  and  obvious.  As  the  proofs  ad- 
duced are  entirely  of  an  historical  character,  there  is  the  probability  of 
confusing  the  names  of  colours  with  the  colours  themselves,  and,  there- 
fore, the  means  of  expression  with  the  power  of  perception.  M.  Delboeul 
has  called  attention  to  the  fact  that  we,  even  now,  have  no  special  desig- 
nations for  odours,  and  our  nomenclature  for  the  various  and  precise  sen- 
sations of  hearing  is  very  incomplete.  Sterner  scientists  have  objected  to 
going  to  poets  for  scientific  data,  even  leaving  out  of  consideration  the 
possibility  that  Homer  may  himself  have  been  colour-blind.  The  asser- 
tions in  reference  to  thj  Rig- Veda  and  Koran  are,  so  far  as  we  know,  un- 
challenged, but  it  is  stated  in  a  recent  communication  to  the  Philadelphia 
Ledger  (July  26),  that  blue  is  mentioned  nine  times  and  green  or  greenish 
forty  times  in  the  Bible.  Looking  back  beyond  man  on  the  scale  of  de- 
velopment, numerous  experiments  have  demonstrated  the  recognition  of 
colours  by  the  lower  animals ;  not  to  go  more  deeply  into  this  subject,  any 


1878.] 


Clarke,  Visions:  a  Study  of  False  Sight. 


475 


fanner's  boy  can  testify  to  a  lively  appreciation  of  red  on  the  part  of  an 
excitable  bull. 

M.  Javal  has  taken  up  the  gauntlet,  and,  avoiding  any  imputation  upon 
his  progressiveness,  has  boldly  accepted  the  theory  of  evolution,  and 
pushed  it  to  a  conclusion  diametrically  opposite  to  that  of  Magnus.  He 
says  there  is  no  reason  to  suppose  that  the  longer  but  less  numerous  waves 
of  the  colours  towards  the  red  end  of  the  spectrum  should  excite  the 
retina  more  powerfully  than  the  shorter  but  more  frequently  repeated 
waves  at  the  other  end.  On  the  contrary,  the  analogy  of  hearing  points 
in  the  opposite  direction.  (The  fact  that  while  the  perception  of  red  is 
confined  to  a  circle  of  the  retina  around  the  macula,  blue  is  perceived 
throughout  the  whole  visual  field,  may  be  of  interest  in  this  connection.) 
It  is  known  that  the  eye  is  not  an  achromatic  instrument,  and  that,  there- 
fore, if  the  less  refrangible  red  rays  are  focussed  accurately  upon  the  re- 
tina, the  more  refrangible  violet  rays  must  be  focussed  in  front  of  it,  and 
fall  upon  it  in  circles  of  diffusion.  The  eye,  therefore,  accommodates  itself 
for  an  intermediate  distance  so  that  the  red  and  violet  circles  of  diffusion 
may  be  made  too  small  to  create  confusion. 

If  evolution  should  add  another  colour  beyond  the  violet,  accommoda- 
tion would  become  more  difficult,  the  circles  of  diffusion  larger,  and  vision 
less  accurate.  This  would  be  to  sacrifice  the  useful  to  the  agreeable.  If 
the  coloured  rays  of  the  spectrum  are  intercepted,  the  invisible  ultra-violet 
rays  become  visible.  These  rays  are  suppressed,  or  rather  neglected,  in 
the  interest  of  accurate  vision,  as  every  visual  sensation  is,  that  would  be 
injurious  to  the  perception  of  external  objects.  "  Then,  contrary  to  the 
views  of  M.  Magnus,  progress,  in  the  domain  of  vision,  should  rather  con- 
sist in  restricting  than  in  increasing  the  extent  of  the  scale  of  colours. 
Pou rq/ioi  pas  ?"  Why  not  ?  indeed,  just  as  we  have  got  rid  of  the  tail 
of  our  fathers.  G.  C.  H. 


Art.  XIX  Visions:  a  Study  of  False  Sight  (Pseudopia).  By  Ed- 
ward H.  Clarke,  M.D.  With  an  Introduction  and  Memorial  Sketch 
by  Oliver  Wendell  Holmes,  M.D.  16mo.  pp.  315.  Boston : 
Houghton,  Osgood  &  Co.,  1878. 

Tins  book  comes  before  us  under  remarkable  circumstances.  The 
author,  who  recently  died  at  the  age  of  57,  had  reached  a  foremost  place 
in  his  profession  and  in  the  respect  and  consideration  of  the  community  in 
which  he  lived  and  died.  Few  men  have  combined  in  a  higher  degree  a 
well-earned  professional  eminence  with  large  general  culture,  and  morals 
and  manners  that  recalled  the  best  type  of  the  gentleman.  With  a  large 
practice,  studious  habits,  and  habitual  association  with  thoughtful  men,  he 
was  well  prepared  to  ponder  the  questions  which  his  profession  was  con- 
stantly presenting,  in  a  purely  philosophical  spirit.  If  he  made  no  great 
achievements  in  original  investigation,  he  had  the  scarcely  less  valuable 
merit  of  measuring  the  claims  of  others  with  profound  insight  and  a  judicial 
impartiality.  His  Sex  in  Education  and  Building  of  a  Brain  are  admi- 
rable examples  of  a  broad  observation,  keen  analysis,  and  dispassionate 
judgment.  In  the  very  maturity  of  his  powers,  with  many  more  years  before 
him,  apparently,  of  an  honorable  career,  he  became  the  victim  of  a  pain- 


476 


R  E  V  I  E  W  S  . 


[Oct. 


ful,  malignant  disease,  and  in  order  to  divert  his  mind  from  his  sufferings, 
he  engaged  in  a  course  of  inquiries  the  result  of  which  we  have  in  the 
volume  before  us.  When  disabled  from  using  his  pen  any  longer,  his  wife 
made  the  record  of  his  progress,  until  she  on  whom  he  also  relied  for  help 
and  comfort  in  the  still  darker  days  that  were  at  hand,  was  removed  by 
sudden  death,  when  the  final  offices  of  affection  devolved  upon  his 
daughter.  After  his  own  death,  the  manuscript  was  consigned  to  his 
friend,  Dr.  Oliver  "Wendell  Holmes,  who  had  visited  him  often  during  his 
illness,  and  discussed  with  him  the  subjects  of  his  investigation,  to  be  dis- 
posed of  as  he  might  think  best.  We  are  glad  that,  though  unfinished,  he 
did  not  hesitate  to  publish  it,  making  no  changes  in  it,  he  says,  of  any 
importance,  and  no  additions  to  it  whatever.  The  reader  is  not  to  expect 
an  elaborate,  well-rounded  treatise,  such  as  it  undoubtedly  would  have 
been  had  the  writer's  life  been  spared  a  little  longer.  He  will  have,  how- 
ever, a  highly  philosophical  essay  full  of  careful  analysis,  ingenious  sug- 
gestions, acute  reasoning,  with  many  interesting  cases.  Dr.  Holmes  intro- 
duces the  book  with  a  brief  account  of  the  author's  life  and  character, 
which,  while  glowing  with  the  warmth  of  friendship  and  admiration,  is 
none  the  less,  we  believe,  a  correct  appreciation  of  those  qualities  of  mind 
and  heart  which  led  to  his  professional  reputation,  and  have  endeared  his 
memory  to  those  who  knew  him  well. 

Dr.  Clarke's  attention  seems  to  have  been  drawn  to  this  subject  by  some 
striking  original  cases  of  hallucination  of  sight  unaccompanied  by  delusion, 
or  mental  aberration.  His  purpose  was  to  furnish  an  explanation  of  these 
phenomena  in  accordance  with  the  accepted  facts  of  anatomy  arid  physi- 
ology and  the  analogies  derived  from  recent  revelations  in  physical  science. 
The  problem  to  be  solved  is,  by  what  process  does  a  person  clearly  per- 
ceive a  sight  or  a  sound  which  has  no  objective  existence.  The  first  step 
towards  a  satisfactory  solution  is  to  ascertain  the  process  by  which  ordinary, 
normal  perception  is  effected.  "  The  apparatus  of  human  vision,"  he  says, 
"  may  be  described  as  a  mechanism  consisting  of  five  organs,  or  sets  of  or- 
gans, which  are  closely  connected,  and  in  intimate  communication  with  each 
other.  They  are  :  (1)  the  eye,  with  the  iris,  lenses,  retina,  and  other  struc- 
tures Avhich  belong  to  it ;  (2)  the  tubercula  quadrigemina  and  associated 
nerves  ;  (3)  the  cerebral  centres  of  vision  in  the  hemispheres,  probably  the 
angular  gyri ;  (4)  the  gray  matter  of  the  frontal  convolutions;  and  (5)  the 
connecting  nerves  of  communication."  Each  member  of  this  apparatus  has 
its  special  function.  "  Each  one  is  supposed  to  do  its  own  part  or  duty 
honestly ;  that  is,  never  to  send  a  report  to  a  station  above  which  it  has 
not  received  from  below ;  and  in  the  vast  majority  of  cases,  such  is  the 
fact.  .  .  .  Nevertheless,  modified  by  disease,  disturbed  by  drugs,  or  influ- 
enced by  the  brain  itself,  they  sometimes  play  false,  manufacture  news, 
like  politicians  and  speculators,  and  send  untrustworthy  reports  to  head- 
quarters." The  functions  of  these  several  members  and  the  successive 
steps  in  the  process  may  be  briefly  stated  thus.  The  eye  receives  the  im- 
pression of  the  waves  of  light,  with  the  colour,  form,  size,  distance,  and 
other  qualities  of  the  object  impressed  upon  it,  but  its  action  is  purely 
automatic  or  mechanical.  By  means  of  the  optic  nerves,  something,  called 
by  the  author  a  visual  impression,  is  transmitted  to  the  tubercula  quadri- 
gemina which  are  charged  with  the  duty  of  coordinating  all  the  automatic 
muscular  movements,  whether  of  the  eye,  or  any  part  of  the  body,  con- 
cerned in  the  act  of  seeing.  Of  all  this,  report  is  made  to  the  angular 
gyrus,  "  which  is  the  last  centre  or  station  of  the  apparatus  which  visual 


1878.]  Clarke,  Visions:  a  Study  of  False  Sight. 


477 


impressions  traverse  on  their  way  from  the  external  world  to  the  frontal 
lobes  where  they  are  turned  over  to  the  machinery  of  ideation  and  volition. 
In  this  centre  they  receive  their  final  elaboration  before  being  presented 
to  the  mind  ;  here  they  are  accurately  registered  and  preserved  for  revival 
or  reproduction.  ...  It  recognizes,  pictures,  and  notes,  every  shade  of 
visual  difference.  .  .  .  Whatever  report  it  sends  up  the  mind  accepts  as 
true.  In  the  vast  majority  of  cases,  it  justifies  by  its  truthfulness  the  con- 
fidence reposed  in  it.  Were  it  not  so,  we  should  never  be  sure  of  any- 
thing we  see.  .  .  .  Now  and  then  the  angular  gyri  do  act  independently 
of  the  external  world,  and  then  we  are  amazed  and  confounded  by  their 
doings."  From  the  angular  gyri  the  visual  impression  is  transmitted  to 
the  frontal  lobes  "  where  it  is  transformed  into  an  idea."  This  is  percep- 
tion. In  another  place  the  process  is  stated  thus:  "  When  light  waves 
from  an  uplifted  dagger  fall  on  the  retina,  the  eye  records  the  facts  of 
colour,  size,  position,  motion,  etc.,  and  transmits  an  account  of  them  to 
the  tubercula  quadrigemina.  This  centre  carefully  adjusts  the  mechanism 
of  the  eye,  the  iris,  lenses,  muscular  apparatus,  and  the  like,  to  the  demands 
of  careful  observation,  coordinates  the  general  muscular  system  for  any 
movement  the  exigency  may  require,  and  makes  its  visual  report  to  the 
angular  gyrus.  The  latter  centre  receives  the  report,  perceives  all  the 
details  of  the  dagger,  the  hand  grasping  it,  the  face  and  action  of  the 
owner,  whatever  constitutes  an  exact  picture  of  the  scene,  and  transmits  a 
corresponding  pictorial  report  to  the  frontal  lobes.  Upon  receiving  this  report 
— this  pictorial  representation — the  lobes  look  at  it,  ascertain  its  significance, 
determine  whether  the  uplifted  dagger  is  raised  for  inspection  merely,  or 
for  a  threatened  or  real  plunge,  or  for  other  purposes,  communicate  with 
the  instincts  and  emotions,  and  decide  the  will  to  act."  The  cells  of  these 
nerve-centres  are  supposed  "  to  retain  or  register  impressions."  Ferrier, 
whose  statement  Dr.  C.  quotes  approvingly,  says,  "  the  angular  gyrus  is, 
like  the  sensitive  plate,  recording  in  cell  modifications  the  visual  charac- 
ters of  the  object  looked  at."  "  And  just  as  the  chemical  decomposition 
effected  by  the  rays  of  light  may  be  fixed  and  form  a  permanent  image  of 
the  object  capable  of  being  looked  at,  so  the  cell  modifications  which  coin- 
cide with  the  presentation  of  the  object  to  the  eye,  remain  permanently, 
constituting  the  organic  memory  of  the  object  itself."  They  can  also  be 
reproduced  "  under  the  influence  of  an  appropriate  and  sufficient  stimu- 
lus," and  the  oftener  they  have  been  formed,  the  more  easily  and  accu- 
rately do  they  arrange  themselves  in  the  same  order.  This  effect  is  also 
facilitated  by  force  of  association  and  habit.  Cell-groups  which  have  been 
dormant  for  years  may  be  called  into  activity  in  quick  succession,  by  any 
incident  which  revives  only  one  of  them.  Considering  the  many  millions 
of  nerve-cells  in  the  ganglionic  centres,  there  can  be  no  lack  of  room  for 
such  registrations  as  long  as  life  endures. 

Such  very  briefly  is  Dr.  Clarke's  account  of  the  manner  in  which  we  see, 
expressed  as  far  as  possible  in  his  own  words.  While  it  does  not  conflict 
with  the  most  approved  results  of  recent  inquiry,  we  scarcely  need  to  say 
that  it  is  not  in  any  degree  the  fruit  of  original,  experimental  investigation, 
nor  indeed  can  it  be  considered  as  a  thoroughly  scientific  deduction  from 
facts  brought  to  light  by  others.  He  admits  that  it  is  largely  hypothetical, 
and  we  readily  admit  that  it  may  claim  the  merit  of  being  a  rational, 
scientific  conjecture  ably  and  gracefully  supported.  The  processes  which 
lead  to  intelligent  vision  are  closely  affiliated  by  Dr.  Clarke  to  those  of 
electro-magnetism,  and  photography.    He  adopts  the  language  specially 


478 


Reviews. 


[Oct. 


used  in  those  sciences  in  order  to  convey  his  views  of  the  cerebral  action 
concerned  in  this  function.  Indeed,  without  them  he  very  probably  would 
have  never  undertaken  to  throw  fresh  light  on  the  mechanism  of  vision. 
One  can  hardly  help  being  impressed  by  the  apparent  analogies  which 
modern  discovery  has  disclosed  between  some  branches  of  physical  science 
and  the  functions  of  the  nervous  system.  It  requires  no  great  stretch  of 
imagination  to  see  in  the  telegraph  wire  and  the  nervous  fibril  a  similarity 
of  office,  or  to  see  in  the  stores  of  negatives  laid  by  in  the  pigeon-holes  of 
the  photographer's  room  the  counterpart  of  that  immense  congeries  of  cell- 
groups  containing  the  recorded  impressions  of  a  life.  AVe  have  no  wish  to 
depreciate  the  aid  thus  obtained  in  the  study  of  the  nervous  system,  so 
long  as  we  are  careful  not  to  mistake  a  means  for  the  end.  A  nerve  is  not 
exactly  like  an  iron-wire,  nor  a  group  of  cerebral  cells  much  the  same 
thing  as  a  bundle  of  sensitive  plates.  Future  discoveries  may  clear  away 
some  of  the  obscurity  in  which  these  analogies  are  involved,  and  thus  give 
a  surer,  broader  foundation  for  this  particular  correlation  of  forces.  In- 
deed, since  this  book  was  written,  the  discovery  of  the  phonograph,  where- 
by sounds  are  registered  and  preserved  for  future  use,  establishes  another 
analogy  between  cerebral  and  mechanical  dynamics. 

AVe  have  admitted  our  author's  explanation  of  the  sense  of  sight  to  be 
a  rational  conjecture,  and  to  some  extent  it  is  certainly  a  strictly  scien- 
tific deduction.  The  eye  receives  a  picture  of  the  object  representing  its 
various  qualities,  such  as  form,  size,  colour,  etc.,  though  the  Doctor's  lan- 
guage leaves  us  in  some  doubt  whether  he  regards  the  perception  of  these 
qualities  as  an  original,  primitive  power,  or.  with  most  physiologists,  as 
the  result  of  education  and  experience.  Thus  far  we  have  only  a  picture, 
and  to  make  it  practically  available  the  eye  is  endowed  with  various  mus- 
cular powers  whereby  it  is  adapted  to  the  varying  circumstances  of  the 
light.  Without  this  power  it  would  be  an  imperfect  instrument  of  sight, 
and  none  the  less  so  without  a  power  somewhere  of  coordinating  the  move- 
ments implied  in  it.  This  office  is  given  to  the  tubercula  quadrigemina, 
and  thus  another  stage  of  the  process  is  accomplished.  Thence  the  im- 
pression is  conveyed  to  the  angular  gyri  on  the  cells  of  which  it  is  inscribed 
and  where  it  becomes  cognizant  to  the  frontal  lobes,  the  source  of  true 
perception.  This  statement,  in  which  he  follows  the  conclusions  of  recent 
inquirers,  furnishes  Dr.  Clarke  an  explanation  of  the  phenomena  of  false 
vision,  or  pseudopia.  as  he  terms  it,  that  would  have  been  unattainable  under 
the  Berkleian  theory  of  vision.  Pseudopia  is  a  phenomenon  strictly  analo- 
gous to  that  well-known  fact  of  sensation  in  a  limb,  days  or  weeks  after  its 
amputation,  and  here  Dr.  Clarke  finds  the  clew  to  his  own  explanation.  In 
the  one  case  as  in  the  other,  a  movement  in  any  part  of  the  apparatus 
concerned  in  the  function  may  be  transmitted  to  the  cerebral  ganglia, 
there  exciting  a  perception  which  by  force  of  habit  refers  the  movement 
to  its  customary  objective  source.  As  our  author  puts  it,  "a  vision  is  pro- 
duced wherever  the  cell-groups  indicating  that  vision — its  hieroglyphic  or 
cipher — are  formed  in  the  brain,  whether  they  are  formed  normally  by  the 
stimulus  of  light -waves  from  an  external  object,  or  abnormally  by  a  stim- 
ulus initiated  intracramally."  He  describes  several  forms  of  pseudopia 
arising  from  different  cerebral  conditions,  being  provoked  sometimes  by 
an  abnormal  habit  like  somnambulism  and  somnolentia  ;  sometimes  by 
active  cerebral  disorder  like  delirium  tremens  ;  sometimes  by  febrile  ex- 
citement the  result  of  colds,  or  influenza  ;  sometimes  by  anxiety  and  mental 
strain  ;  sometimes  by  stimulants  ;  sometimes  by  an  act  of  volition  aided 


1878.] 


Clarke,  Visions:  a  Study  of  False  Sight. 


479 


by  habit,  association,  and  emotion.  And  the  starting  point  may  be  a 
shadow  or  other  objective  stimulus,  or  it  may  be  intracranial,  entirely 
subjective.  Whichever  it  maybe,  "it  initiates  a  customary  sort  of  motion 
in  the  visual  apparatus,  which  determines  the  apparatus  to  produce  of 
itself,  automatically,  the  cell-groups  and  modifications  that  are  to  go 
through  an  habitual  action  representing  some  external  object."  It  would 
greatly  exceed  our  limits  to  give  Dr.  Clarke's  comments  on  all  the  cases 
he  describes,  and  therefore  we  must  confine  ourselves  to  a  notice  of  one  or 
two  only. 

Mrs.  B.,  a  lady  thirty  years  old,  experiences  a  hallucination  when  about 
to  suffer  some  sort  of  febrile  attack,  like  a  cold  or  simple  fever,  or  gastric 
derangement,  and  it  disappears  when  the  attack  is  fully  developed.  Sud- 
denly there  appears  to  her  the  figure  of  a  woman  with  averted  face,  dressed 
in  white,  coming  unbidden  at  any  time  of  day  or  night,  sometimes  sitting, 
sometimes  standing,  and  sometimes  walking.  Once  when  dining  out,  as 
she  approached  the  place  assigned  to  her  at  the  table,  she  found  the  chair 
occupied  by  her  "  familiar  spirit."  She  thrust  her  fan  into  it,  when  it 
moved  aside  and  vanished.  "  It  will  sometimes  take  a  chair  and  sit  near 
where  she  is  reading,  or  at  work,  or  by  her  bed,  by  the  half-hour  or  hour 
together,  and  then  vanish  suddenly."  "  It  would  be  impossible,"  says  Dr. 
Clarke,  "  to  gather  from  her  account  the  details  of  the  process  by  which  old 
and  disused  cell-groups  were  so  completely  revived.  All  the  conditions, 
however,  for  the  production  of  pseudopia  were  present.  She  was  naturally 
endowed  with  an  excitable  and  nervous  temperament.  She  witnessed  in 
childhood  an  occurrence — a  death — under  circumstances  of  distress  and 
horror,  such  as  are  seen  by  few,  and  which  made  a  profound  and  perma- 
nent impression  upon  her.  Her  emotions  were  excited,  at  the  time,  to 
such  a  degree,  that  she  could  never  afterwards  allude  to  the  event  without 
distress.  Later  in  life  she  became  subject  to  the  febrile  attacks  just  men- 
tioned, which  were  attended  with  slight  cerebral  congestion.  At  such 
periods  the  brain  cells,  including  those  of  the  visual  apparatus,  were  tem- 
porarily flushed  with  blood,  and  therefore  just  in  the  state  to  be  called  into 
activity  by  the  slightest  stimulus." 

In  the  case  of  a  very  similar  hallucination  which  we  met  with,  three  or 
four  years  since,  the  subject,  a  middle-aged  lady,  the  predisposing  causes 
were  an  excessively  nervous  temperament  raised  into  a  morbid  activity  by 
domestic  troubles  and  malarial  exposure.  At  the  periods  when  she  suffered 
most,  she  would  see,  when  she  awoke  in  the  morning,  a  woman  unknown 
to  her  sitting  at  the  foot  of  her  bed.  After  a  few  minutes  the  apparition 
would  rise  and  glide  through  the  side  of  the  room.  Dr.  Clarke  relates,  among 
others,  the  case  of  an  old  man  whose  hallucinations  were  both  optical  and 
auditory.  He  saw  three  persons  in  his  bedroom,  habited  as  public  singers 
usually  are,  who  entertained  him  with  excellent  singing,  between  the  pieces 
chatting  with  one  another  in  Italian.  They  appeared  but  once.  "  He  was 
an  ardent  lover  of  music,  and  a  frequenter  of  concerts  and  musical  enter- 
tainments. During  a  long  life  his  brain  cells  had  been  often  grouped  at 
the  sound  of  music,  and  at  the  sight  of  musical  performers."  There  was 
some  cerebral  congestion,  and  he  finally  died  of  brain  disease.  Under 
such  conditions,  favourable  as  they  were  to  functional  derangement  of  the 
nerve  centres.  "  the  slightest  stimulus  would  be  sufficient  to  put  in  motion 
the  whole,  or  a  part  of  his  intracranial  machinery.  While  sleeping,  the 
notes  of  a  serenade,  or  the  whistling  of  a  boy  in  the  street,  or  even  the 
excitement  of  a  dream,  would  be  enough  to  arouse  his  automatic  cerebral 


480 


Reviews. 


[Oct. 


apparatus  into  musical  activity.  .  .  .  His  visual  and  auditory  centres 
had  acquired  the  habit,  on  musical  matters,  of  acting  together."  The 
incidental  parts  of  the  hallucination,  such  as  the  dress  of  the  performers, 
the  preliminary  clearing  of  the  throat,  and  talking  between  the  pieces, 
were  all  repetitions  of  a  familiar  experience.  "  Groups  of  old  visual  and 
auditory  cells  moved  in  and  out  of  his  field  of  seeing  and  hearing,  and  were 
telegraphed  to  his  ideational  centres,  as  honest  reporters  of  objective  sights 
and  sounds." 

In  all  the  cases  described  by  Dr.  Clarke,  the  apparition  was  preceded 
by  some  nervous  disturbance  ;  but  though  this  is  unquestionably  the  gen- 
eral rule,  yet  we  apprehend  it  is  not  without  exceptions.  A  case  once 
came  to  our  notice  the  subject  of  which,  an  elderly  physician,  we  know, 
on  the  best  possible  authority,  had  experienced  no  unusual  exercise  of 
mind  or  feeling,  nor  had  his  attention  been  particularly  drawn  to  any  thing 
directly  or  indirectly  connected  with  the  subsequent  occurrence.  On  his 
way  to  the  summer  residence  of  a  friend,  he  observed,  when  within  a  hun- 
dred feet  of  the  house,  a  lady  without  bonnet  or  shawl  passing  along  by  the 
side  of  the  house  towards  its  front,  which  was  not  within  sight  from  the  ap- 
proach until  the  visitor  nearly  reached  it.  He  expected,  of  course,  to  meet 
her  on  the  piazza,  but  found  no  one  there,  nor  was  there  any  appearance 
of  the  house  being  occupied.  A  few  moments  after,  he  met  the  gardener 
at  work  near  by,  who  told  him  that  Mrs.  S.  was  very  ill  in  the  city,  that 
none  of  the  family  had  come  down,  that  the  house  had  not  been  opened, 
and  that  no  one,  man  or  woman,  had  recently  been  on  the  grounds.  We 
are  not  sure  how  it  will  affect  the  spiritual  faith  of  such  people  as  believe 
in  the  night  side  of  nature  class  of  books,  to  be  told  t  hat  Airs.  S.  did  not 
die  till  nine  or  ten  hours  afterwards,  but  such  was  the  fact. 

We  have  now  given  the  reader  a  clew  to  Dr.  Clarke's  philosophy  ot 
vision,  true  and  false;  and  though  we  are  not  prepared  to  give  our  assent  to 
it  in  every  particular,  we  are  willing  to  admit  that,  resting  as  it  does  on  the 
latest  researches  in  cerebral  physiology  and  discoveries  in  other  sciences,  it 
is  ingenious,  rational  and  plausible,  if  not  entirely  satisfactory.  At  any 
rate,  we  believe  that  the  legitimate  influence  of  the  book  on  some  popular 
doctrines  of  our  time  will  be  good,  for  at  the  least,  it  will  show  how  little 
foundation  they  have  in  the  truths  of  science.  It  knocks  away  one  of  the 
strongest  pillars  of  spiritualism,  for  what  better  evidence  could  it  have 
than  the  testimony  of  the  senses  ?  When  some  shadowy  spectre  bearing 
the  lineaments  of  a  departed  friend,  glided  into  the  room  and  sat  down  by 
the  side  of  the  observer,  was  he  not  bound  to  regard  it  as  a  visitor  from 
the  spirit  world  ?  The  subjective  character  of  apparitions  has  been  recog- 
nized by  scientific  men,  but  it  has  never  been  a  part  of  the  popular  belief; 
and  even  those  too  well  informed  to  believe  in  ghosts  could  give  no  better 
explanation  of  them  than  to  refer  them  to  some  unintelligible  play  of  the 
imagination.  We  may  add  that  few  are  aware  how  much  in  the  mental 
operations  of  common  life  the  subjective  is  mistaken  for  the  objective,  and 
yet  the  close  observer,  once  cognizant  of  the  fact,  cannot  fail  to  see  it 
frequently  exemplified.  It  explains  very  much  of  that  discrepancy  in  the 
testimony  of  witnesses  in  courts  of  justice,  which  surprises  and  perplexes 
all  who  hear  it.  To  this  source  undoubtedly,  we  must  attribute  most  ot 
those  confessions  of  criminal  acts  which  never  had  an  objective  existence. 
A  person  strongly  impressed  by  the  story  of  a  crime,  dwelling  curiously 
on  its  circumstances,  and  forming  pictures  of  the  scene,  and  especially  if 
he  is  of  an  excessively  nervous  temperament,  becomes,  at  last,  the  subject 


1878.]  Clarke,  Visions:  A  Study  of  False  Sight. 


481 


of  a  reflex  movement  whereby  he  is  made  the  actor  in  the  scene.  A 
notable  illustration  of  this  phenomenon  is  given  by  Southwood  Smith  in  his 
book  on  Forensic  Medicine.  A  mutiny  occurred  on  board  an  English 
national  ship,  ending  in  the  murder  of  the  captain,  Pigot.  The  crew  took 
the  vessel  into  a  foreign  port  where  some  of  them  were  arrested,  sent  home 
and  executed.  The  rest  of  the  story  is  thus  related  by  Mr.  Finlaison,  the 
government  actuary,  who  was  then  employed  in  the  Admiralty.  "  In  my 
own  experience  I  have  known,  on  separate  occasions,  more  than  six  sailors 
who  voluntarily  confessed  to  having  struck  the  first  blow  at  Captain  Pigot. 
These  men  detailed  all  the  horrid  circumstances  of  the  mutiny  with  ex- 
treme minuteness  and  perfect  accuracy ;  nevertheless,  not  one  of  them 
had  ever  been  in  the  ship,  nor  had  so  much  as  seen  Captain  Pigot  in  their 
lives.  They  had  obtained  by  tradition  from  their  messmates  the  particu- 
lars of  the  story.  When  long  on  a  foreign  station,  hungering  and  thirsting 
for  home,  their  minds  became  enfeebled  ;  at  length  they  actually  believed 
themselves  guilty  of  the  crime  over  which  they  had  so  long  brooded,  and 
submitted  with  a  gloomy  pleasure  to  being  sent  to  England  in  irons  for 
judgment." 

Dr.  Clarke  alludes  to  the  visions  of  sleep,  of  the  dying,  and  of  the  insane, 
but  says  only  enough  to  lead  us  to  regret  that  the  opportunity  had  not  been 
afforded  him  to  make  these  also  the  subject  of  a  special  investigation.  "** 

I.  R. 


No.  CLII  Oct.  1878.  31 


482 


[Oct. 


ANALYTICAL  AND  BIBLIOGRAPHICAL  NOTICES. 

Art.  XX. — Transactions  of  the  American  Gynaecological  Society.    Vol.  II. 
For  the  year  1877.    8vo.  p.  697.    Boston  :  Houghton,  Osgood  &  Co.,  1878. 

It  will  be  impossible  within  a  reasonable  space  to  give  even  a  condensed  re"sum6 
of  the  various  papers  in  the  very  creditable  volume  before  us ;  we  shall  therefore 
confine  our  remarks  to  such  of  them  as  are  most  novel  and  instructive.  As  the 
Society  numbers  but  forty-six  active  Fellows  it  shows  how  much  valuable  work 
may  be  done  by  a  few  working  members.  The  last  annual  meeting  was  held  in 
Boston  on  May  30,  31,  and  June  1,  1877  ;  the  next  will  have  closed  in  this  city 
before  this  issue  of  the  Journal  shall  have  appeared. 

Amputation  and  Excision  of  the  Cervix  Uteri ;  their  Indications  and  Methods. 
— In  this  paper  Dr.  John  Byrne,  of  Brooklyn,  X.  Y.,  advocates  the  removal 
of  the  cervix  generally  in  cases  of  cancer,  "whether  the  disease  be  confined 
to  a  small  portion  of  the  lip  only,  or  the  entire  circumference  of  the  cervix 
be  involved."  He  recommends  the  same  method  in  many  cases  of  "great  en- 
largement from  cervical  hypertrophy,  especially  those  met  with  in  the  lower  and 
middle  walks  of  life  ;  in  hypertrophic  elongation  of  the  cervix,  and  in  aggravated 
granular  conditions  of  the  cervix,  and  cystic  degeneration.  He  prefers  the 
galvano-cautery  for  the  ablation,  and  says  that  he  has  never  had  a  case  of  hem- 
orrhage after  the  removal  of  a  hypertrophied  cervix.  The  time  required  "  should 
seldom  be  less  than  ten,  and  often  fifteen  minutes."  He  claims  that  cicatricial 
stenosis  is  rare  after  this  form  of  removal,  having  seen  but  four  cases  in  nearly 
fifty  operations.  He  also  states  that  the  galvano-cautery  exercises  a  restraining 
effect  upon  the  growth  and  return  of  cancer  of  the  cervix,  and  that  in  several 
cases  reported,  cures  had  apparently  been  effected,  as  there  had  been  no  return 
in  periods  varying  from  two  to  seven  years. 

Dr.  Goodell  had  removed  the  cervix  more  than  thirty  times,  and  the  only  fatal 
results  had  occurred  after  the  galvano-cautery ;  one  died  of  peritonitis  in  forty- 
eight  hours,  one  of  secondary  hemorrhage  on  the  twenty-first  day,  the  second 
attack,  and  the  third  died  also  after  two  hemorrhagic  seizures.  Dr.  G.  had  never 
seen  cicatricial  contraction  of  the  cervix  to  the  extent  of  occlusion  after  the  ablation. 
He  advocated  the  use  of  the  galvano-cautery  as  the  preferable  method  of  excis- 
ion. Dr.  Goodell  believes  that  the  cachexia  of  cancer  has  no  special  connection 
with  its  specific  character  or  malignancy,  as  it  may  be  made  to  disappear  under  a 
treatment  temporarily  arresting  the  growth  and  discharge,  although  the  constitu- 
tional taint  may  remain  in  force. 

Dr.  John  Scott,  of  San  Francisco,  took  exception  to  the  treatment  recom- 
mended in  the  paper,  and  stated  that  his  experience  had  taught  him  just  the  con- 
trary. He  advocated  excision  for  cases  of  epithelioma,  but  deprecated  it  in  other 
forms  of  cancer,  or  in  the  disease  in  advanced  stages  ;  he  believes  the  operation 
to  be  a  fruitful  source  of  stenosis. 

Dr.  W.  H.  Byford  believed  in  amputation  of  the  cervix  for  malignant  disease. 
He  thought  cancerous  cachexia  was  due  to  a  species  of  septicemia  resulting  from 
the  disintegration  of  the  tissues  and  absorption  of  the  poison,  and  that  death  also 
resulted  in  this  way ;  hence  he  advocated  the  removal  of  the  decomposing  mass. 


1878.]      Transactions  of  the  American  Gynaecological  Society.  483 


Dr.  Noeggerath  had  amputated  the  cervix  forty-one  times,  all  but  six  by  the 
galvano-cautery ;  secondary  hemorrhage  in  two  of  the  former ;  eighteen  cases 
were  malignant ;  in  eight  there  had  been  no  return,  one  being  of  six  years'  stand- 
ing and  another  four.  In  seven  cases  pregnancy  subsequently  occurred.  Con- 
striction of  the  os  resulted  in  one  of  the  thirty-five  cautery  removals,  but  was 
cured  by  pregnancy  and  delivery  a  year  afterward. 

Dr.  John  C.  Dalton,  of  New  York,  presented  a  Report  on  the  Corpus  Lu- 
teum,  which  is  beautifully  illustrated  with  twelve  chromo-lithographs  of  ovaries, 
presenting  the  various  conditions  in  which  the  yellow  body  is  found  Dr.  Dalton 
prepared  the  article  at  the  request  of  the  Society,  the  specimens  being  furnished 
in  answer  to  a  circular  sent  to  professional  friends.  There  were  thirty-two  pairs 
of  ovaries,  eight  of  which  were  removed  from  non-pregnant  women  within  the 
four  weeks  of  a  regular  menstrual  interval,  six  after  an  interval  of  from  five  to 
eleven  weeks,  six  in  which  the  menses  had  been  absent  from  four  months  to  a 
year,  and  two  pairs  after  an  interval  of  six  years  or  more.  There  were  also  four 
cases  of  abortion  from  third  to  sixth  month ;  and  six  of  death  from  one  to  eight 
days  after  delivery  at  or  about  full  term. 

We  have  been  particular  in  noting  the  material  used,  as  it  will  be  impossible 
to  condense  the  reports  of  the  cases,  which  are  very  minutely  described.  To 
show  the  progress  of  development  and  recedence,  Dr.  D.  gives  the  weights  of 
the  corpora  lutea  in  the  eight  cases  observed  soon  after  menstruation,  viz.,  2 
days  after,  380  milligrammes;  9  days,  430;  10  days,  810;  15  to  20  days,  1230; 
20  days,  1200;  6  weeks,  90;  10  weeks,  20;  and  11  weeks,  15  milligrammes. 

Case  XVII.  deserves  especial  notice,  as  an  evidence  that  menstruation  may 
take  place  without  the  rupture  of  Graafian  follicles,  or  formation  of  corpora 
lutea.  The  subject  was  a  young  epileptic  girl  who  died  after  sixteen  hours'  ill- 
ness, eight  days  after  a  moderate  menstrual  How,  verified  by  personal  inspection 
of  the  nurse  in  a  hospital,  where  she  had  menstruated  at  regular  intervals  on  two 
former  occasions.  The  ovaries  were  normal  in  size  and  appearance,  the  right 
showing  an  enlarged  and  prominent  follicle,  with  a  transparent  covering,  as  if 
approaching  the  menstrual  maturity.  In  neither  ovary  were  there  any  of  the 
usual  physiological  changes  that  follow  the  menstrual,  period.  Dr.  Dalton  ex- 
presses the  opinion  that  the  coincidental  ovarian  development  was  about  to  com- 
mence shortly  in  this  case ;  and  that  the  same  want  of  coincidental  action  between 
the  flow  and  follicle  may  occur  at  the  closing  of  menstrual  life. 

As  diseases  necessarily  retard  or  modify  the  menstrual  function  with  its  ovarian 
changes,  the  most  reliable  observations  must  be  those  made  after  death  by  vio- 
lence ;  in  which  event  the  previous  history  is  often  wanting,  so  that  the  valuable 
cases  must  be  exceedingly  limited.  The  well-known  accuracy  of  Prof.  Dalton 
makes  his  paper  a  very  valuable  contribution  to  obstetric  science. 

The  Pathology  and  Treatment  of  Puerperal  Eclampsia  is  the  title  of  a 
paper  by  Prof.  Otto  Spiegelberg,  of  Breslau,  Prussia,  in  which  he  controverts 
the  theory  of  Frerichs,  that  urea  is  changed  in  the  blood  into  carbonate  of  ammo- 
nia, and  that  this  becomes  the  cause  of  convulsions.  He  found  ammonia  present 
in  the  blood  in  three  cases,  but  only  in  minute  quantities,  and  believes  it  to  be  one 
of  the  rarest  causes  of  convulsions. 

He  also  opposes  the  theory  of  Traube  and  Rosenstein,  that  the  eclampsia  re- 
sults from  increased  arterial  pressure,  producing  acute  oedema  of  the  brain  in 
hydremic  subjects,  ending  in  coma,  the  fact  being  that  hydremic  women  are  not 
specially  subject  to  convulsive  attacks. 

Prof.  S.  attributes  the  eclampsia  to  the  want  of  renal  action,  whereby  the  urea 
accumulates  in  the  blood  to  a  poisonous  extent.  He  believes  that  this  failure  of 
the  kidney  is  due,  not  to  mechanical  congestion,  unless  it  be  in  a  few  exceptional 


434 


Bibliographical  Notices. 


[Oct. 


cases,  but  to  some  defective  condition  of  the  minute  bloodvessels  of  the  kidney, 
whether  to  degeneration  of  their  walls  or  spasmodic  contraction  he  is  not  prepared 
to  say.  Eclamptic  or  epileptiform  attacks  also  result  from  reflex  disturbance 
originating  within  the  pelvis,  from  an  over-distended  bladder  or  an  irritable  os 
uteri. 

Treatment. — Prophylactic — where  there  is  kidney  trouble,  employing  alkaline 
diuretics,  vegetable  acids,  purgatives,  tonics,  and  warm  baths.  Where  there  are 
premonitory  symptoms,  venesection,  chloral  by  rectum,  morphia  hypodermically. 
Induction  of  premature  labour  not  recommended.  In  true  eclampsia  he  recom- 
mends venesection  as  the  most  reliable  means  of  relief — 6  ounces  in  ordinary 
cases,  and  15  or  16  in  robust  women,  the  bleeding  being  repeated  if  not  effectual. 
Narcotics  immediately  after  the  venesection,  muriate  of  morphia,  chloral,  chloro- 
form not  safe,  but  may  be  given  during  a  paroxysm  ;  cold  applications  to  head, 
and  local  depletion,  in  coma ;  a  full  dose  of  calomel  and  jalep,  followed  by  an 
enema  of  ol.  ricini  and  ol.  terebinth.,  aa  f^ss,  in  chamomile  tea.  The  speedy 
completion  of  labour  is  also  highly  important. 

Dilatation  of  the  Cervix  Uteri  for  the  Arrest  of  Hemorrhage  is  the  title  of  a 
paper  read  by  Dr.  G.  H.  Lyman,  of  Boston,  Mass.  As  menorrhagia  is  a  very 
common  ailment  in  our  country,  any  truly  philosophical  method  of  relief  must  be 
of  great  value.  Dr.  Lyman  believes  that  in  large  measure  the  cause  of  metror- 
rhagia lies  in  a  uterine  congestion,  produced  by  strangulation  of  the  circulation  at 
the  internal  os  uteri,  and  to  relieve  this,  recommends  the  wide  dilatation  of  the 
cervix  by  means  of  sea-tangle  tents.  He  gives  five  typical  cases  to  show  the 
marked  benefit  of  the  treatment. 

In  No.  1  the  hemorrhage  was  very  profuse  ;  dilatation  revealed  the  existence 
of  a  fibroid  at  the  internal  os ;  no  other  complication  ;  next  menstrual  period  no 
excess  ;  third  slight  increase  ;  woman  being  48,  then  ceased  to  menstruate ;  fibroid 
diminished,  and  health  became  re-established. 

No.  2  was  single,  and  28 ;  subject  to  exhausting  metrorrhagia,  which  was  lia- 
ble to  seize  her  under  any  emotional  impulse  or  muscular  effort.  Uterus  of  nor- 
mal length  and  in  place  ;  patient  affected  with  vaginismus,  which  was  first  treated  ; 
dilatation  of  uterus  revealed  nothing  abnormal,  but  resulted  in  her  menstrual 
periods  becoming  finally  regular  and  normal. 

No.  3,  27,  married  three  years,  never  pregnant;  uterus  enlarged  to  three  and 
a  half  inches  in  length,  dilated  with  tents  ;  small  portions  of  hypertrophied  mu- 
cous membrane  removed  with  curette,  and  tincture  of  iodine  applied.  Case 
much  improved;  uterus  diminished  to  nearly  normal  size,  and  flow  decidedly 
checked,  although  not  perfectly,  as  the  circumstances  of  the  patient  would  not 
admit  of  the  required  rest  and  treatment. 

No.  4,  36,  married  15  years,  one  child,  has  had  leucorrhoea  two  years,  menor- 
rhagia 3  weeks  out  of  4,  for  about  nine  months,  and  confined  most  of  the  time  to 
bed.  Uterus  dilated,  no  fibriods,  walls  thiekened,  with  pulpy  masses  in  the  cavity, 
considerable  masses  of  hyperplastic  mucous  membrane  removed  with  placental 
forceps,  no  hemorrhage  or  constitutional  disturbance,  carbolized  vaginal  injections 
used,  and  Bland's  pills.  Next  menstrual  period  lasted  six  days,  profuse  on  third 
day,  but  not  menorrhagic.  Two  years  and  a  half  later,  occasional  slight  prolon- 
gation of  periods,  looks  and  feels  well,  not  been  confined  to  bed  a  day. 

Dr.  D.  H.  Storer,  of  Boston,  mentioned  two  cases  in  which  very  marked  relief 
from  menorrhagia  had  followed  the  use  of  the  sponge-tent.  Dr.  Wilson  of  Bal- 
timore had  frequently  observed  the  same  effect. 

Dr.  Albert  H.  Smith,  of  Philadelphia,  had  repeatedly  used  the  sponge- tent 
to  relieve  certain  forms  of  metrorrhagia  ;  especially  where  there  existed  a  granular 
endometritis,  associated  with  hyperplasia  of  the  body  of  the  uterus ;  and  to  cause 
a  diminution  of  uterine  enlargement,  resulting  from  inflammatory  hypertrophy, 
or  imperfect  involution.   He  cautioned  the  Fellows  against  using  the  tent  in  cases 


1878.]      Transactions  of  the  American  Gynaecological  Society. 


485 


of  possible  malignancy,  and  reported  one  where  this  condition  not  being  suspected, 
he  had  by  the  dilatation  caused  a  rupture  of  the  uterus.  He  recommended  the 
use  of  one  large-sized  sponge-tent,  capable  of  expanding  to  a  diameter  of  from 
one  to  two  inches,  and  introduced  from  a  half  to  three-quarters  of  an  inch  through 
the  internal  os,  there  to  remain  forty-eight  hours.  He  regarded  the  use  of  one 
tent  as  fraught  with  little  danger,  the  fear  being  from  a  repetition,  after  the  with- 
drawal of  the  first.  To  avoid  any  septic  trouble  he  recommended  an  injection  of  2 
gr.  permanganate  of  potash  every  three  hours,  which  the  sponge  would  be  found 
on  removal  to  have  absorbed. 

Dr.  Scott,  of  San  Francisco,  spoke  of  the  danger  of  the  use  of  the  tent  in  acute 
or  subacute  cellulitis.  He  recommended  after  the  removal  of  the  tent,  in  metror- 
rhagia cases,  that  the  uterus  should  be  washed  out  with  water  at  110°  to  115°  and 
then  tincture  of  iodine  injected. 

Dr.  Goodell,  of  Philadelphia,  believed  that  sponge  was  also  useful,  from  the 
i'act  that  it  withdrew  in  its  meshes  small  polypi  and  portions  of  the  hypertro- 
phied  lining  membrane  of  the  uterus,  the  existence  of  which  favoured  the  hemor- 
rhagic tendency. 

In  a  paper  on  The  Principles  of  Gynaecological  Surgery  applied  in  Obstetric 
Operations,  Dr.  A.  J.  C.  Skene,  of  Brooklyn,  New  York,  recommends  the  use  of 
the  Sims  speculum  in  dangerous  and  difficult  obstetric  operations,  so  that  by  the 
advantage  of  sight,  better  security  against  injury  may  be  obtained.  In  craniotomy 
he  places  the  patient  on  her  left  side  ;  introduces  a  large  speculum ;  supports  the 
anterior  vaginal  wall  and  uterine  lip  by  a  retractor  ;  uses  Braun's  perforator, 
cutting  several  openings,  and  removing  the  intervening  plate  ;  removes  the  brain 
with  a  curette,  and  long-handled  sponge  ;  separates  the  scalp  from  the  skull  by  a 
uierine  sound,  and  then  picks  away  the  cranial  bones,  etc. 

In  prolapse  of  the  funis,  he  uses  the  speculum  in  the  knee-elbow  position,  pushes 
up  the  cord  Avith  sponges  in  long  holders,  and  secures  the  advantage  gained  by 
descent  of  the  head,  replacing  the  patient  on  her  side  during  the  pain. 

Dr.  Skene  has  also  applied  the  fillet  to  breech  presentations,  and  uses  Barnes's 
dilator  with  much  advantage,  by  using  the  speculum ;  and  suggests  its  employ- 
ment in  shoulder  and  arm  presentations. 

Dr.  William  T.  Lusk,  of  New  York,  read  a  paper  On  the  Necessity  of  Cau- 
tion in  the  Use  of  Chloroform  during  Labour,  in  which  he  expressed  his  belief 
that  "not  a  small  number  of  persons  have  quietly  abandoned  chloroform  as  a  pain- 
stilling  agent,  because  some  incident  in  their  practice  has  led  them  to  suspect  that 
in  spite  of  statistics  it  possesses  dangerous  properties."    (Page  203.) 

The  author  divides  his  subject  according  to  the  following  heads:  "  1st.  Deep 
ancesthesia,  carried  to  the  point  of  complete  abolition  of  consciousness,  in  some 
cases  iceakens  uterine  action  and  sometimes  suspends  it  altogether."  By  this  effect 
we  secure  the  required  muscular  relaxation  where  version  is  to  be  performed  ;  but 
after  turning,  this  very  condition  should  be  regarded  as  a  dangerous  obstacle  to 
the  immediate  removal  of  the  foetus,  the  inertia  of  the  uterus  endangering  hemor- 
rhage ;  hence  the  importance  of  waiting  the  removal  of  action,  by  the  diminution 
of  anaesthesia  AYe  have  especially  noted  this  effect  in  many  cases  of  labour  under 
ether. 

"2d.  Chloroform,  even  given  in  the  usual  obstetrical  fashion,  namely,  in  small 
doses,  during  the  pains  only,  and  after  the  commencement  of  the  second  stage,, 
may,  in  exceptional  cases,  so  far  weaken  uterine  action  as  to  create  the  necessity 
for  resorting  to  ergot  or  forceps.  I  think,  if  statistics  were  to  be  gathered 
together  on  this  point,  it  would  be  found  that  those  who  habitually  use  chloroform 
in  normal  labour  resort  to  forceps  with  somewhat  increased  frequency."  (Page 
205.)    An  inquiry  would  no  doubt  also  establish  the  fact  that  this  adynamic  effect 


486 


Bibliographical  Notices. 


[Oct. 


in  sulphuric  ether  in  labour,  was  the  main  cause  of  the  large  falling  off  in  its 
use,  the  objection  coming  both  from  obstetrician  and  patient. 

' '  3d.  Patients  in  labour  do  not  enjoy  any  absolute  immunity  from  the  pernicious 
effects  of  chloroform."  It  has  been  so  strongly  contended,  particularly  in  Great 
Britain,  that  parturient  women  enjoyed  a  special  immunity  against  the  dangers  of 
chloroform,  that  this  heading  throws  down  the  gauntlet  to  many  of  our  trans- 
Atlantic  medical  brethren.  Dr.  Lusk,  however,  is  ready  to  back  up  his  opinion 
with  cases  in  proof,  of  which  he  gives  five,  all  the  patients  being  free  from  cardiac 
or  pulmonary  complications. 

Case  I. — 22,  married,  second  pregnancy,  brought  to  Bellevue  Hospital  in  labour, 
shoulder  presentation,  and  prolapsed  funis,  which  had  ceased  to  pulsate.  Dr. 
Lusk  saw  her  ten  hours  after  rupture  of  membranes.  Squibb' s  chloroform  given  to 
relax  uterus  in  aid  of  version,  patient  struggled,  assistant  closed  the  funnel  over 
the  respiratory  passages,  and  "almost  instantly  the  patient  ceased  to  breathe,  and 
became  pulseless."  After  being  with  difficulty  resuscitated,  it  was  found  that 
alarming  symptoms  were  reproduced  by  the  slightest  inspiraton  of  the  anaesthe- 
tic ;  the  woman  was  strong,  healthy,  and  free  from  lung  or  heart  affection. 

Case  II. — Primipara,  30.  Chloroform  in  second  stage,  and  only  during 
pains  ;  had  been  given  over  two  and  a  half  hours,  and  but  a  few  drops  at  a  time, 
when  the  patient  after  half  a  dozen  deep  inspirations  suddenly  ceased  to  breathe, 
and  her  pulse  ceased.  Dr.  Joel  Foster,  who  was  in  charge,  used  Marshall  Hall's 
method,  and  she  was  restored.  The  total  amount  of  chloroform  used  in  the  two 
hours  and  a  half  was  less  than  half  an  ounce. 

Case  III. — Same  patient  in  a  second  confinement.  A  little  chloroform  given 
by  Dr.  Elliot  on  a  handkerchief  during  pains  ;  same  effect  as  before  ;  same 
method  used,  and  same  fortunate  result.  Labour  completed  without  the  anaesthe- 
tic, and  patient  did  well. 

Case  IV. — Primipara,  22,  under  care  of  Dr.  Cotting.  Head  about  emerging 
when  slight  convulsion  took  place.  Chloroform  given,  and  repeated  during  re- 
turning pains ;  tremor  occurred  and  pulse  ceased.  No  cause  of  death  found  except 
the  giving  of  chloroform. 

Case  V. — Multipara,  25.  Shoulder  presentation  ;  labour  protracted.  Chlo- 
roform given  preparatory  to  version,  under  direction  of  a  sister  of  charity  in 
charge  of  the  hospital  ward.  As  patient  did  not  rouse  after  inhalation,  surgeon 
called  in,  who  found  a  thready  pulse,  face  blue,  and  respiration  imperfect.  In 
ten  minutes  the  woman  died. 

"4th.  Chloroform  should  not  be  given  in  the  third  stage  of  labour.  Ihe  rela- 
tive safety  of  chloroform  in  parturition  ceases  with  the  birth  of  the  child. " 

Dr.  Lusk  believes  the  use  of  chloroform  dangerous,  in  cases  of  hour-glass  con- 
traction, placental  retention,  and  where  the  perineum  is  to  be  sewed  up,  as  the 
uterine  relaxation  induced  favours  hemorrhage.  He  advises  against  the  use  of  the 
anaesthetic  in  cases  where  there  has  been  hemorrhage  to  any  considerable  extent, 
even  if  a  day  has  intervened,  the  cerebral  anaemia  increasing  very  materially  the 
risk. 

"  5th.  The  more  remote  influence  of  large  doses  of  chloroform,  during  labour, 
upon  the  puerperal  state,  is  a  subject  that  calls  for  further  investigation  and 
inquiry.'" 

When  the  system  becomes  as  it  were  saturated  with  chloroform,  to  be  removed 
by  an  eliminative  process,  the  secondary  depressive  effect  of  the  anaesthetic  may 
endanger  the  life  of  the  woman,  especially  if  she  has  become  anaemic  by  reason 
of  post-partum  hemorrhage. 

rlhe  Present  Status  of  the  Intra-uterine  Stem,  in  the  Treatment  of  Flexions  of 
the  Uterus. — In  this  paper  Dr.  Ely  Van  de  Warker,  of  Syracuse,  N.  Y.,  en- 
deavours to  disabuse  the  minds  of  medical  men  of  what  he  conceives  to  be  an  error, 
in  regard  to  their  estimate  of  the  risk  of  using  the  stem  pessary  in  the  treatment 
of  uterine  flexures .;  and  to  revive  a  resort  to  the  same,  as  a  needlessly  abused 


1878.]     Transactions  of  the  American  Gynecological  Society.  487 


instrument.  Thirty  years'  experience  has  not  proved  very  favourable  to  the  em- 
ployment of  this  apparently  simple  and  philosophical  little  appliance,  which  phy- 
sicians were  at  first  disposed  to  accept  as  a  valuable  discovery,  until  it  gradually 
became  revealed,  that  it  was  by  no  means  as  safe  and  innocent  as  it  appeared.  A 
reaction  of  a  very  unfavourable  character  set  in  against  it ;  its  first  active  advo- 
cates almost,  and  in  some  instances  entirely,  abandoned  its  use ;  changes  were 
rung  upon  its  shape  and  material ;  and  now  we  learn  by  the  discussion  reported 
in  the  volume  before  us,  what  estimate  is  placed  upon  it  by  our  leading  gynaecolo- 
gists, some  of  whom  have  had  an  extensive  experience  with  its  use.  We  will 
give  a  very  condensed  risum.6  of  the  views  expressed. 

Dr.  Chadwick,  of  Boston,  recommended  an  elastic  ring  pessary,  with  a  slender 
hard-rubber  flexible  stem  attached,  having  an  olive-shaped  bulb  at  the  free  end, 
and  the  other  fixed  in  a  button-shaped  shield.  He  had  used  this  instrument  in  a 
number  of  cases  ;  in  two,  of  chronic  metritis  and  peritonitis,  metrorrhagia  had 
been  induced,  in  no  other  instance  were  there  unpleasant  symptoms. 

Dr.  Peaslee,  of  New  York,  was  in  general  decidedly  opposed  to  the  stem  pes- 
sary, except  in  certain  forms  and  degrees  of  flexion ;  did  not  employ  it  in  any 
case  of  retroflexion,  would  use  it  in  some  extreme  cases  of  anteflexion,  preferred 
in  general  an  elastic  intravaginal  pessary. 

Dr.  T.  G.  Thomas,  of  New  York,  was  opposed  to  anything  like  a  general  use 
of  the  stem  pessary,  on  account  of  the  damage  attending  it  in  some  cases  ;  was  a 
pupil  of  Yalleix,  and  at  one  time  an  advocate  of  the  instrument,  but  had  changed 
his  views  by  time  and  experience,  having  met  with  several  cases  of  induced  cel- 
lulitis and  peritonitis ;  he  felt  that  its  sphere  should  be  limited,  and  the  danger  of 
its  use  properly  recognized.  He  believed  that  the  vaginal  pessary  was  competent 
to  relieve  most  of  the  cases  of  flexure,  and  recommended  several  forms  which  he 
presented. 

Dr.  Noeggerath,  of  New  York,  advocated  the  use  of  the  stem  pessary.  Had 
employed  it  in  dysmenorrhea  and  sterility  coincident  with  anteflexion,  and  ex- 
ceptionally in  retroflexion  ;  used  a  lead  stem  two  and  an  eighth  inches  long,  with 
Conant's  hard-rubber  rings  ;  had  used  it  in  more  than  a  hundred  cases,  with  three 
serious  consequences,  viz.  :  1,  htematocele  at  beginning  of  menstruation  ;  2,  acute 
mania  from  pain  immediately  after  removal,  in  a  lady  previously  affected  in  the 
same  way  by  excessive  menstrual  pain  ;  and  3,  pelvic  peritonitis  and  death,  the 
inflammation  beginning  immediately  after  the  removal  of  the  instrument.  Dr. 
Noeggerath  usually  inserts  the  stem,  under  anaesthesia,  at  the  house  of  the 
patient. 

Dr.  Goodell,  of  Philadelphia,  had  changed  his  views  by  experience  in  favour  of 
the  instrument,  although  at  one  time  opposed  to  it,  in  consequence  of  trouble  set 
up  in  two  cases.  Used  the  glass,  or  smooth  rubber  stem,  or  the  split  one  with  the 
arms  having  a  weak  spring ;  took  ca»e  that  the  same  should  not  reach  the  fundus 
by  half  an  inch.  Never  introduced  the  instrument  in  his  office ;  before  the  first 
introduction,  secured  the  button  with  a  strong  traction- thread,  for  the  patient  to 
use  in  removing  the  instrument,  if  pain  should  go  on  from  bad  to  worse ;  cut 
away  the  string  as  soon  as  the  uterus  became  tolerant ;  had  had  no  bad  result 
under  these  precautions,  but  always  felt  apprehensive  of  coming  evil  whilst  using 
the  instrument,  and  relieved  at  its  final  removal.  Dr.  G.  had  a  case  of  dysmen- 
orrhea with  anteflexion,  in  which  impregnation  took  place  with  the  split  stem  in 
situ;  the  instrument  was  withdrawn,  and  the  pregnancy  advanced.  He  gave 
preference  to  the  Hodge  closed  lever  pessary,  introduced  wrong  end  first,  for  the 
vaginal  support  in  cases  of  anteflexion. 

Dr.  A.  H.  Smith,  of  Philadelphia,  also  gave  preference  to  the  Hodge  pessary,  as 
modified  by  himself;  could  not  endorse  the  enthusiastic  praise  given  in  the  paper 


488 


Bibliographical  Notices. 


[Oct. 


of  Dr.  Van  de  Warker ;  had  seen  excellent  results  from  the  intra-uterine  stem  in 
retroflexion,  of  the  retort  form,  leaving  the  instrument  in  situ  temporarily,  until 
the  tissues  at  the  point  of  flexion  should  become  so  modified  as  to  remain  unbent 
after  the  stem  is  removed. 

Dr.  W.  L.  Atlee,  of  Philadelphia,  believed  all  forms  of  pessaries  to  be  injurious ; 
he  thought  that  simple  change  of  position  in  the  uterus  would  occasion  no  marked 
inconvenience,  unless  the  organ  or  pelvis  were  unhealthy,  and  if  so,  then  he  di- 
rected his  treatment  to  restore  the  part  affected  to  a  normal  condition. 

Dr.  Wilson,  of  Baltimore,  endorsed  the  views  of  Dr.  Atlee.  Had  never  seen  a 
pessary  benefit  an  anteversion  ;  had  used  stem  pessaries  twelve  years  ago  in  their 
various  forms,  but  had  abandoned  them  entirely  ;  had  employed  the  Hodge  pes- 
sary in  anteflexion  after  the  manner  recommended  by  Goodell,  but  invariably 
without  success. 

Dr.  Byford,  of  Chicago,  believed  that  flexions  were  due  to  pathological  condi- 
tions, and  that  to  effect  a  cure,  not  only  should  the  primary  condition  but  its 
result  be  overcome.  "If  the  pathological  condition  is  not  corrected,  a  straight- 
ening of  the  flexion  is  of  no  use."  He  recommended  the  use  of  tents  of  slippery 
elm  bark,  with  a  thread  attached,  to  remain  from  three  to  twelve  hours,  and  be 
removed  by  the  patient  if  pain  is  produced :  one,  three,  or  five  tents  may  be 
required.  Dr.  Byford  dilates  the  cervix  by  these  tents,  using  as  many  as  a  dozen 
in  the  course  of  half  an  hour ;  he  also  treats  dysmenorrhea  by  the  use  of  a  tent 
four  or  five  times  in  a  month,  the  last,  two  days  before  the  period  ;  he  never  uses 
the  intra-uterine  stem. 

Dr.  Skene,  of  Brooklyn,  thought  that  the  abandonment  of  the  stem  pessary  by 
its  early  advocates  was  a  strong  argument  against  it  ;  he  had  seen  bad  results 
from  its  careful  use,  and  stated  that  after  being  long  worn  the  flexion  remained, 
or  returned  after  its  withdrawal. 

Dr.  Garrigues,  of  Brooklyn,  remarked  that  Olshausen,  of  Halle,  had  seven 
patients  with  cellulitis,  out  of  eighty-eight  treated  by  the  stem  ;  he  spoke  of 
Squarey's  flexible  rubber  stem  pessary  as  the  most  likely  to  be  tolerated  by  the 
uterus  in  cases  of  dysmenorrhea. 

Dr.  William  Goodell,  of  Philadelphia,  reported  the  following  Case  of  Va- 
ginal Ovariotomy : — 

Woman  22,  single,  health  failing  for  two  years:  uterus  behind  symphysis; 
tumour  in  Douglas's  pouch  ;  sound  measurement  four  inches;  admitted  into  Hos- 
pital of  University  of  Pennsylvania;  aspirator  used  Feb.  21,  187  7,  and  a  large 
tumbler  and  a  half  of  fluid  drawn  out,  which,  under  examination,  was  pronounced 
ovarian.  Patient  much  relieved  from  pressure  inconveniences  for  a  time ;  but 
cyst  filled  again,  and  was  retapped  by  aspiration  on  March  3d,  the  fluid  being 
turbid,  somewhat  sanious,  having  a  slight  odour  of  sulphuretted  hydrogen,  and 
measuring  nearly  a  quart.  Symptoms  of  blood  poisoning  appeared,  fever,  loss 
of  appetite,  hectic  flushes,  sweating,  and  finally  incessant  vomiting;  pulse  120: 
temperature  102.5°.  Woman  alarmed,  and  consented  to  operation  of  removal, 
which  was  performed  on  March  14th.  Several  ounces  of  fetid  pus  escaped  on 
opening  Douglas's  pouch  ;  numerous  adhesions  found;  fluid  from  cyst  drawn  off, 
amounting  to  two  quarts,  a  dirty,  grumous  pus,  with  highly  offensive  gas ;  a 
second  cyst  contained  about  an  ounce  of  clear  syrupy  fluid.  Cyst  without  pedicle  ; 
transfixed  at  base,  and  tied  around  each  half,  then  cut  away.  Several  smaller 
cysts  found,  with  contents  unchanged,  and  some  calcareous  plates.  No  peritonitis 
resulted  ;  septic  symptoms  gradually  subsided,  and  woman  recovered. 

This  case  shows  the  danger  of  aspiration,  and  the  importance  of  extirpation 
following  it  as  soon  as  possible.  The  delay  was  here  unavoidable,  as  the  patient 
only  gave  consent  when  in  fear  of  death. 

Dr.  Goodell  reports  seven  operations,  all  American,  and  all  ending  in  recovery. 
He  advocates  the  removal  of  post-uterine  cysts,  while  small  and  non-adherent. 


1878.]      Transactions  of  the  American  Gynaecological  Society.  489 


A  chief  advantage  in  some  cases  is  that  of  drainage,  the  discharge  being  very 
abundant. 

Dr.  Chadwick  was  of  the  opinion  that  where  the  discharge  was  serous,  it  ought 
to  be  retained,  to  keep  the  intestines  separated,  and  prevent  adhesions. 

Dr.  Noeggerath  treated  even  large  cysts  by  incision,  and  stitching  the  vaginal 
to  the  cyst  wound,  so  as  to  drain  out  the  tumour.  Small  cysts  he  punctured,  and 
emptied  with  a  fine  cutting  canula,  and  had  thus  treated  about  ten,  the  largest 
containing  some  three  ounces  of  fluid.  He  had  twice  ruptured  thin  cysts  by 
pressure  exerted  by  one  hand  over  the  abdomen,  and  the  other  in  the  vagina. 

Is  there  a  Proper  Field  for  Battey's  Operation  ?  is  the  title  of  a  paper  by  Dr. 
Robert  Battey,  of  Rome,  Georgia.  We  have  entered  upon  this  question  on 
a  former  occasion,  which  is  one  about  which  there  will  necessarily  be  much  dif- 
ference of  opinion.  It  is  generally  conceded  that  Dr.  Battey  is  perfectly  honest 
in  his  convictions,  and  humane  in  dealing  with  his  cases,  upon  which  he  operates 
with  the  best  intentions  ;  but  there  is  great  danger  of  unnecessarily  unsexing  the 
patient*  and  also  failing  in  the  desired  result,  even  if  she  escape  death.  There 
is  certainly  a  field  for  the  operation,  and  great  relief  may  be  atforded  by  it ;  but 
the  field  is  very  limited,  and  we  should  be  sure  that  there  is  no  other  possible 
remedy.  There  are  existences  that  are  worse  than  death ;  the  life  being  ren- 
dered intolerable  by  reason  of  pain  and  exhaustion,  due  to  the  functional  activity 
of  the  ovaries.  We  have  seen  women  that  would  have  been  much  better  without 
their  ovaries ;  but  whose  condition,  notwithstanding,  would  not  have  justified 
their  removal ;  and  we  have  known  others,  in  whom  the  operation  could  not  have 
been  reasonably  objected  to.  Such  cases  as  that  reported  by  Dr.  Goodell,  in  this 
Journal  for  July  last,  page  36,  are  certainly  proper  subjects  for  this  operation. 
Knowing  well  the  continued  and  excessive  suffering  of  this  lady  before  the  ope- 
ration, we  can  appreciate  her  feeling  of  gratitude  at  the  wonderful  result  of  its 
performance. 

Dr.  Theophilus  Parvin,  of  Indianapolis,  Indiana,  reports  a  Case  of  Ova- 
riotomy followed  by  Fatal  Tetanus,  which,  in  our  climate,  is  a  very  rare  sequence 
of  ovariotomy.  Dr.  Parvin' s  patient  became  affected  on  the  fifth  day,  and  died 
on  the  sixth.  He  gives  a  table  of  thirteen  operations  ending  in  tetanus,  with  but 
one  recovery. 

The  value  of  Electrolysis  in  the  Treatment  of  Ovarian  Tumours  is  discussed 
by  Dr.  Paul  F.  Munde,  of  New  York.  There  is  a  disposition  at  the  present 
day  to  decry  the  use  of  the  knife  ;  not  because  there  is  a* better  plan  to  be  sub- 
stituted for  it,  but  for  the  reason  that  the  great  mass  of  the  community  has  a 
mortal  fear  of  an  incision,  and  will  endure  almost  anything  rather  than  have  a 
morbid  mass  cut  out ;  hence  a  cure  without  cutting  becomes  a  popular  road  to 
fortune ;  and  claims,  far  beyond  the  real  merit  of  the  method  adopted,  are  by  a 
species  of  charlatanic  urging,  made  to  deceive  the  suffering  and  sometimes  even 
the  profession. 

The  question  of  the  proper  treatment  of  ovarian  tumours  is  too  important  to 
allow  any  method  which  offers  hope  of  better  results  than  is  now  obtained  by 
ovariotomy  to  pass  without  careful  and  impartial  examination  of  its  alleged  ad- 
vantages and  disadvantages,  and  the  determination  of  its  exact  value.  This  Dr. 
Munde  has  undertaken  to  do  for  the  electrolytic  method,  and  he  has  given  the 
whole  question  a  most  thorough  sifting,  and  his  deductions  are  only  the  natural 
results  of  the  cases  presented.  Had  Dr.  Semeleder  remained  in  Mexico,  instead 
of  going  to  New  York  in  1875,  his  claims  to  success  in  electrolysis  might  have 
been  difficult  to  overthrow ;  but  the  results  of  the  cases  treated  by  him,  and  of 
those  treated  by  others,  according  to  his  directions,  during  his  visit  to  that  city,  were 


490 


Bibliographical  Notices. 


[Oct. 


not  successful,  but  did  much  to  establish  the  value  of  the  process  as  a  means  of 
cure. 

The  investigations  of  Ultzmann,  of  Vienna,  have  settled  several  questions  of 
interest.  1.  The  cysts  most  amenable  to  electrolytic  treatment  are  those  which 
contain  a  watery  sero-albuminous  fluid;  2.  Cysts  filled  with  thick,  viscid,  honey- 
like fluid  are  scarcely  diminished  by  the  strongest  currents ;  3.  Electrolysis  is 
positively  injurious  where  the  fluid  contents  are  composed  of  decomposed  blood  or 
pus,  producing  at  once  symptoms  of  peritonitis ;  4.  The  galvano-puncture  does 
cause  adhesions  of  the  cyst  with  the  omentum,  or  abdominal  wall ;  5.  The  cystic 
fluid  changes  under  electrolysis,  and  pus  corpuscles  may  be  developed,  to  disappear 
in  time;  6.  Cases  apparently  cured,  will  return  in  time  with  tumours  as  large  as 
ever.  7.  Electrolysis  with  failure,  complicates  the  case  for  the  operation  by  the 
knife. 

Dr.  Munde  reports  51  cases,  resulting  as  follows,  via.,  cured,  25;  permanently 
improved,  3  ;  temporarily,  4  ;  no  benefit,  6  ;  peritonitis,  with  recovery,  4 ;  peri- 
tonitis, with  death,  9.  Compare  with  this  the  ovariotomy  report  of  the  Samari- 
tan Hospital  for  1876,  and  we  find  50  cures  and  5  deaths,  under  Spencer  Wells. 

The  author  sums  up  his  conclusions  as  follows :  "Judging  partly  from  these 
statistics,  and  partly  from  general  considerations,  it  would  seem  that  electrolysis 
can  in  no  wise  supplant  ovariotomy,  and  that  the  cases  in  which  it  would  appear 
justifiable  to  subject  the  patients  to  the  tedious  and  protracted  course  of  galvano- 
puncture  usually  indispensable  to  the  attainment  of  any  results,  good  or  evil, 
narrow  themselves  down  to  two  classes :  1 .  Small  monocysts,  in  which  the  dis- 
comforts are  so  slight  as  to  render  the  more  serious  radical  operation  as  yet  un- 
called for,  and  in  which  it  seems  fair  to  give  the  patient  a  probable  chance  of  a 
cure  by  milder  means  ;  and  2.  Particularly  large  unilocular,  or  multilocular  tu- 
mours, in  which  the  presence  of  extensive  adhesions,  especially  in  the  pelvis, 
renders  ovariotomy  impracticable,  and  in  which  a  palliative  procedure  is  desi- 
rable and  admissible,  so  long  as  it  affords  the  patient  a  hope  of  relief,  and 
temporary  prolongation  of  life.    (Page  435.) 

"There  is  one  method  of  electrical  treatment  which  at  least  is  almost  innocuous, 
and  may  therefore  be  employed  if  the  condition  of  the  patient  permits  the  delay. 
This  is  external  galvanization  or  faradization,  by  both  of  which  methods  cures  of 
ovarian  tumours  are  reported  by  reliable  authorities." 

When  we  consider  that  even  a  complete  cure  by  the  galvanic  current  cannot  be 
relied  upon  for  permanence,  because  the  ovary  is  still  in  situ  to  take  on  disease  at 
any  time,  we  recognize  how  little  real  value  there  is  in  any  method  of  treatment 
as  compared  with  the  ablation  of  the  diseased  organ.  If  patients  were  candidly 
informed  as  to  this  point,  there  would  be  fewer  anxious  to  avoid  the  knife. 

Congenital  Absence,  and  Accidental  Atresia  of  the  Vagina;  mode  of  Ope- 
rating to  establish  the  Canal  and  Evacuate  retained  Menstrual  Blood,  is  the 
title  of  a  contribution  by  Dr.  Thomas  Addis  Emmet,  of  Xew  York.  It  is  well 
known  that  this  class  of  cases,  particularly  where  there  is  an  accumulation  of 
menstrual  fluid,  has  been  for  a  long  time  regarded  as  in  many  instances  dangerous 
to  relieve  by  evacuation  ;  even  the  opening  of  an  imperforate  hymen,  whether  by 
large  or  small  incision,  having  resulted  in  death.  Various  theories  have  been 
advanced  to  account  for  this  result,  but  Dr.  Emmet's  cases  and  treatment,  when 
measured  by  his  success,  would  appeal'  to  solve  the  question  of  danger.  Simple 
evacuation  by  incision  will  not  answer,  as  the  parts  remain  coated  with  a  tarry 
deposit,  which  by  the  admission  of  air  becomes  decomposed,  and  inflammatory 
changes  or  septic  infection  are  set  up.  All  the  blood  must  therefore  be  removed 
and  the  uterus  and  vagina  made  clean,  which  Dr.  Emmet  accomplishes  by 
syringing  with  warm  water  until  the  same  comes  away  colourless. 


1878.]     Transactions  of  the  American  Gynaecological  Society.  491 


Twenty-two  cases  are  given  in  this  report  as  the  experience  of  the  author,  all 
of  which  recovered,  viz.,  Imperforate  hymen,  with  retention  from  one  to  two 
and  a  half  years,  4  ;  congenital  absence  of  the  vagina,  7 ;  accidental  atresia  from 
childbirth,  9  ;  the  same  from  injury,  1 ;  the  same  from  amputation  of  cervix 
with  galvano-cauteiy,  1. 

Results  of  Operating. — Imperforate  hymen  cases,  no  after-difficulty.  3  cases  of 
restored  vagina  with  retention  resulted  in  cellulitis  in  1.  1  case  where  no  uterus 
could  be  found  at  the  time  of  operation,  subsequently  menstruated.  In  3  women 
there  was  apparently  no  uterus.  1  case  of  early  traumatic  atresia  developed 
rapidly  to  womanhood  after  restoring  the  vagina.  In  the  9  women  with  atresia 
following  childbirth,  all  had  retained  menses,  and  but  one  suffered  an  attack  of 
cellulitis  after  evacuation  and  irrigation.  The  atresia  from  amputation  was 
relieved  from  time  to  time,  but  there  was  no  hope  of  entire  cure. 

Dr.  Emmet  remarks  upon  amputation  of  the  cervix  as  follows :  "When  the 
crown  of  the  cervix  is  removed  above  the  vaginal  junction"  by  the  galvano-cau- 
tery,  "stenosis  is  a  very  frequent  occurrence  within  two  years  after  the  operation. 
Where  the  surface  is  left  to  heal  by  granulation,  cicatricial  tissue  must  necessarily 
be  formed,  and  it  cannot  be  denied  that  this  tisue  always  contracts,  therefore  ste- 
nosis must  be  a  common  result.  But  whenever  the  vaginal  tissue  is  included,  we 
have  a  more  serious  condition  to  deal  with.  In  healing,  it  contracts  over  the 
stump,  as  if  drawn  with  a  running-string,  so  that  the  uterus  becomes  at  length 
covered  by  two  thicknesses  of  the  vaginal  wall."    (Page  468.) 

Dr.  E.  claims  to  have  originated  the  plan  of  completing  the  operation  of  vagi- 
nal restoration  or  formation  at  one  sitting ;  of  freely  separating  the  tissues  by- 
passing the  finger  from  one  side  to  the  other  in  the  pelvis;  to  have  given  free 
exit  to  the  retained  menses;  and  to  have  washed  out  the  uterus  with  warm  water 
to  prevent  blood-poisoning. 

Dr.  George  J.  Engelmann,  of  St.  Louis,  Mo.,  discusses  The  Hystero-Xeu- 
roses,  with  special  reference  to  the  Menstrual  Hystero-Neurosis  of  the  Stomach. 
It  is  well  known  to  the  profession  in  general  that  the  uterus  is  the  fons  et  origo 
malt  in  many  of  the  nervous,  painful,  and  mental  affections  of  women.  This 
highly  sensitive  organ  appearing  in  many  unaccountable  ways,  even  when  scarcely 
at  all  diseased,  to  act  as  a  centre  of  reflex  disturbance  upon  almost  every  part  of 
the  economy.  How  or  why  this  is  done  we  are  left  only  to  conjecture.  AY  e  see 
the  multitudinous  effects,  and  trace  them  often  by  an  accident  to  their  proper  ori- 
gin ;  we  treat  a  discovered  abnormity,  so  slight  it  may  be,  that  but  for  the  teaching 
of  experience  we  should  be  inclined  to  ignore  it  altogether,  and  the  patient  re- 
covers ;  and  we  find  again  the  same  organ  seriously  deranged,  without  any  sym- 
pathetic disturbance  whatever.  The  author  defines  the  meaning  of  the  title  to 
his  paper  as  follows  :  — 

' '  By  this  term  hystero-neuroses,  I  would  designate  those  phenomena  which 
simulate  a  morbid  condition  of  an  organ,  unaccompanied  by  any  structural 
changes  in  that  organ,  and  which  are  the  result  of  a  reflex  action,  a  sympathetic 
hyperajsthesia,  due  to  uterine  derangements,  and  demonstrated  to  be  unquestion- 
ably so  dependent  by  being  intractable  to  direct  local  medication,  but  yielding  at 
once  upon  treatment  of  the  casual  pelvic  disorder." 

"They  are  entirely  distinct  from  the  transitory  and  variable  symptoms  of  hys- 
teria which  I  am  inclined  to  place  among  the  cerebro-spinal  affections,  and  which 
are  but  very  indirectly  influenced  by  the  condition  of  the  uterus  or  its  annexa. 
Moreover,  the  hystero-neuroses  are  generally  found  in  women  who  can  by  no 
means  be  called  hysterical  in  the  sense  in  which  this  word  is  necessarily  used." 
(Page  483.) 

"In  their  early  stages  purely  nervous,  they  are  at  once  and  permanently 
removed  by  relieving  the  disease  of  the  uterus.  Should  this,  however,  continue, 
structural  changes  will  gradually  develop  in  the  organs,  which  are  the  seat  of 


492 


Bibliographical  Notices. 


[Oct. 


the  hystero-neurosis,  so  that  in  the  end  we  shall  actually  find  the  disease,  which 
was  at  first  only  simulated,  by  irritation  of  a  certain  set  of  nerves." 

"These  hystero-neuroses  may  be  more  or  less  continuous,  due  to  chronic 
uterine  disease,  or  only  appearing  at  certain  times  during  exacerbation  of  such 
disease ;  they  may  also  be  brought  about  by  the  physiological  changes  of  men- 
struation, or  of  pregnancy  in  an  irritable  or  diseased  womb,  and  we  may  hence 
classify  them  in  accordance  with  their  causative  connection,  as  constant  or  patho- 
logical hystero-neuroses,  menstrual  hystero-neuroses,  and  hystero-neuroses  of 
pregnancy."    (Page  484.) 

The  author  for  the  purposes  of  illustration  divides  his  subject  into  the  following 
heads : — 

"  Hystero-neuroses  of  the  brain."  lt  Gynaecologists  have  paid  but  little  atten- 
tion to  this  subject,  and  the  text-books  give  us  either  very  unsatisfactory  infor- 
mation, or  do  not  even  refer  to  the  fact  that  a  relation  may  exist  between  diseases 
of  the  womb  and  mental  aberration.  We  owe  our  entire  knowledge  of  these 
conditions  to  the  close  and  careful  observation  of  Louis  Mayer,  of  Berlin,  and 
Fordyce  Barker,  of  Xew  York."    (Page  486.) 

Six  cases  are  given  in  illustration ;  one  or  two  will  suffice  to  show  the  condi- 
tions involved.    The  first  could  hardly  be  classed  as  reflex. 

Case  I. — Mrs.  V.  ;  40;  melancholia;  increase  at  each  menstrual  period;  no 
abnormity  of  sexual  organs  as  to  size,  character,  or  position ;  and  flow  regular 
and  without  pain. 

Shroeter  observed  the  cases  of  212  insane  women,  and  found  that  the  larger 
proportion  had  menstrual  irregularity ;  but  in  no  one  was  a  regulation  of  the 
function  attended  with  a  restoration  to  reason. 

It  is  very  difficult  to  establish  the  exact  utero-mental  connections  of  insanity, 
as  they  may  be  direct  or  indirect  and  retroactive.  "We  have  seen  repeated 
attacks  of  alienation  due  to  menstrual  excess,  the  result  of  a  residence  in  a  hot 
climate,  cured  by  removal  to  a  much  colder  region.  Hemorrhage  was  no  doubt 
only  partly  the  cause,  as  the  hyperemia  of  the  uterus  must  have  been  an  active 
reflex  factor  in  the  case. 

Case  II. — Girl,  1 7  ;  well  developed  and  robust ;  daily  epileptic  ;  menstruation 
irregular  and  scanty;  anteflexion;  erosions;  endo-cervicitis.  Nitric  acid  to 
cervix  ;  no  fit  for  five  days ;  then  gradually  returned  at  shorter  intervals.  Bi- 
lateral incision  of  cervix  with  dilatation  ;  menses  became  regular ;  slippery  elm 
tents  used,  and  occasional  applications  to  the  lining  of  cervix.  Epilepsy  ceased, 
and  healthy  mental  condition  restored. 

Case  III. — Girl,  18;  amenorrhea,  erosions,  endo-cervicitis  ;  pale,  undeveloped, 
almost  idiotic,  complete  hemiplegia.  Mind  defective  ;  sometimes  remained  in 
bed  in  an  unconscious  state  for  weeks.  A  monthly  exacerbation  marked,  with 
headache,  backache,  and  often  vomiting.  Vaginitis  and  vaginismus  found  on 
examination.  Treatment  established  the  menstrual  flow,  cured  the  vaginal  and 
uterine  affections,  caused  the  girl  to  become  well  developed,  and  removed  her 
mental  and  physical  disabilities,  except  the  paralysis,  which  was  improving  under 
electricity. 

"  Hystero-neuroses  of  the  eye."  These  are  confined  to  those  cases  in  which 
defective  vision  is  directly  the  result  of  uterine  abnormity,  and  not  due  to  any 
structural  change  which  the  ophthalmoscope  can  detect.  Cases  of  amaurosis 
during  pregnancy  and  lactation  ;  and  of  extravasation  of  blood  in  the  retina  during 
cerebral  and  pulmonary  congestion  resulting  from  amenorrhoea  and  dysmenorrhea, 
are  not  of  this  class.  Blindness  may  appear  in  a  few  hours  without  cerebral  con- 
gestion, and  disappear  as  rapidly. 

Dr.  Engelmann  also  describes  hystero-neuroses  of  the  pharynx,  larynx; 
bronchi,  with  obstinate  cough  relieved  only  by  treatment  addressed  to  the  uterus, 
after  all  other  means  have  failed ;  of  the  breasts,  intestines,  joints,  and  stomach. 


1878.]      Transactions  of  the  American  Gynaecological  Society.  493 


The  last  are  much  the  most  common,  and  may  be  directly  pathological,  or  the 
result  of  menstruation  or  pregnancy. 

Uterine  disease  is  a  very  common  cause  of  indigestion,  nausea,  and  vomiting, 
which  are  relieved  or  cured  by  treating  the  primary  lesion.  Stenosis  of  the 
cervix  may  act  as  an  exciting  cause  in  producing  obstinate  vomiting  and  repeated 
convulsive  attacks  which  will  only  yield  to  incision  and  dilatation.  We  have 
seen  very  obstinate  vomiting  result  from  the  use  of  a  sponge-tent  within  a  few 
days.  "  Menstrual  hystero-neuroses  of  the  stomach"  are  not  at  all  uncommon, 
particularly  in  the  form  of  swelling,  with  either  pain,  nausea,  or  vomiting.  Dr. 
Engelniann  estimates  that  from  one-fourth  to  a  third  of  the  inmates  in  a  general 
hospital  for  women  are  thus  affected. 

Papers  presented  to  the  Council  by  the  Candidates  elected  to  Felloivship  in 
1877. — Dr.  Gilman  Kimball,  of  Lowell,  Mass.,  presented  some  cases  illustrat- 
ing important  points  connected  with  ovariotomy. 

Case  I. — Shows  the  advantage  of  drainage  through  the  Douglas  pouch  and 
vagina  ;  and  benefit  of  an  early  change  to  solid  diet. 

Case  IT. — Bleeding  from  abraded  peritoneum  controlled  by  torsion  of  the 
larger  vessels,  and  by  hand  pressure  for  half  an  hour  or  more,  with  thick  compresses 
of  cotton  cloth.  Wound  was  closed  with  quilled  sutures,  "  the  lips  of  the  incision 
being  first  everted  to  such  an  extent  as  effectually  to  exclude  nearly  all  that  por- 
tion of  the  inner  surface  of  the  parietes  to  which  the  tumour  had  been  attached." 
The  whole  cyst  and  contents  weighed  100  pounds.  On  the  10th  day  she  took 
solid  food  ;  sat  up  on  20th  ;  almost  healed  on  23d. 

Case  III. — Peritonitis  already  commenced  at  time  of  incision,  extensive  parie- 
tal adhesions,  abraded  parts  everted,  not  less  than  ninety  square  inches  shut  off 
from  the  peritoneal  cavity,  torn  surfaces  secured  by  cylindrical  clamps  an  inch  and 
a  half  long,  and  third  of  an  inch  in  diameter,  canula  inserted  in  Douglas's  fossa 
for  drainage,  much  putrid  matter  thus  escaped,  and  septic  poisoning  avoided. 

Case  IV. — A  considerable  portion  of  omentum  ligatured  and  cut  away  to  arrest 
hemorrhage  due  to  adhesions  broken  up  between  it  and  front  of  tumour,  drainage 
established  through  vagina,  with  good  effect. 

Case  V. — Cyst  ruptured  from  a  fall;  woman  emaciated  and  bedridden  ;  abdo- 
men 60  inches  in  circumference  ;  patient  70  years  old  ;  thirty  pounds  of  fluid  in 
abdomen  from  ruptured  cyst ;  extensive  adhesions  ;  lacerated  parts  tied  with  silk 
cut  short  ;  vaginal  and  abdominal  tubular  drainage  established ;  wound  closed  by 
five  clamp  or  quilled  sutures  two  inches  apart.  The  damaged  peritoneal  surface 
thus  excluded  from  the  abdominal  cavity  was  not  less  than  seven  inches  in  width, 
and  ten  in  length.  Slow,  but  good  recovery;  tumour  81  pounds.  The  abdo- 
minal tube  found  very  effective  for  drainage,  and  antiseptic  washing. 

1  he  Radical  Treatment  of  Dysmenorrhcea  and  Sterility  by  rapid  Dilatation  oj 
the  Canal  of  the  Neck  of  the  Uterus. — In  this  paper  Dr.  Ellwood  Wilson,  of 
Philadelphia,  says,  that  for  the  past  five  years  he  has  abandoned  incisions  and  the 
use  of  tents,  and  resorted  exclusively  to  rapid  dilatation  in  the  management  of 
painful  menstruation,  whether  the  contraction  be  due  to  congenital  formation, 
catarrhal  or  other  inflammation,  or  flexions.  For  this  purpose  he  has  devised  a 
curved  instrument  in  three  sizes,  opening  by  pressing  the  handles  together,  either 
by  the  hands,  or  aided  by  screw  power,  the  tips  of  the  three  representing  the 
sizes  5,  8,  and  11  of  the  English  catheter. 

In  using  the  dilator,  etherization  is  employed  in  sensitive  cases,  but  may  be 
dispensed  with  in  many  subjects  ;  and  the  operation  is  performed  through  a  spe- 
culum ;  Nott's  self-retaining  being  preferred.  "  Should  the  resistance  be  marked, 
the  blades  are  only  partially  expanded  and  slightly  withdrawn,  when  they  are 
again  closed  and  carried  a  little  further  on,  and  expanded,  and  this  is  repeated 
until  the  internal  os  is  passed, ' '  the  smallest  sized  dilator  being  first  used,  and  if 
requisite,  the  second  and  largest  in  order.  "Performed  in  this  manner,  dilata- 
tion of  the  neck  of  the  uterus  has  never  in  my  hands  been  followed  by  any  un- 


494 


Bibliographical  Notices. 


[Oct. 


toward  symptoms.  It  is  of  course  painful,  but  rarely  for  more  than  a  few 
minutes.  If  carefully  conducted,  the  hemorrhage  and  discomfort  are  so  very  tri- 
fling that  I  not  unfrequently  resort  to  it  in  my  office,  the  patient  walking  or  riding 
home  after  a  short  rest.  She  should  keep  quiet  for  forty-eight  hours,  but  beyond 
this  precaution,  no  after-treatment  is  necessary." 

Appended  to  the  paper  of  Dr.  Wilson,  are  the  reports  of  eleven  cases  in  which 
the  instrument  was  used.    We  give  the  points  of  interest :  — 

Case  I. — Married  13  years;  barren;  menstruation  painful  and  scanty;  had 
had  her  cervix  frequently  dilated  by  tents  and  bougies,  with  temporary  ameliora- 
tion. Dilator  used  to  full  extent  in  January,  1873,  and  again  in  February,  just 
before  menstrual  attack  ;  menses  free  and  voided  without  pain  ;  March  period, 
did  not  confine  her  to  bed,  the  first  time  in  years  ;  delivered  of  a  living  child  in 
December,  1873. 

Case  II. — Married  11  years;  very  similar  ;  also  became  a  mother. 

Cases  III.,  IV.,  V.,  all  became  pregnant ;  Case  IV.  having  had  three  children 
since  the  dilatation,  which  was  done  on  three  occasions. 

Case  VI. — Married  2  years;  uterus  very  small  and  irregularly  developed ; 
sound  measurement,  only  23  lines.  Dilator  used  at  intervals  of  7  to  14  days  for 
eleven  months,  by  which  time  the  sound  passed  2£  inches,  and  menstruation  was 
regular,  free,  painless,  and  lasted  five  days  ;  became  pregnant,  but  aborted  at 
three  months  from  exertion  and  over-fatigue. 

Four  of  the  remaining  cases  were  single,  and  all  cured  of  painful  menstruation 
after  the  same  treatment. 

Vascular  Tumours  of  the  Female  Urethra  is  the  title  of  a  paper  by  Dr.  A. 
Reeves  Jacksox,  of  Chicago,  111.  These  are  more  frequent  than  is  usually 
supposed,  and  should  be  suspected  to  exist  if  there  is  pain  in  urination,  a  fre- 
quent desire  to  urinate,  and  bleeding  at  the  close  of  the  act.  In  bad  cases,  there 
may  be  sudden  stoppage  of  the  flow,  with  spasm  of  the  bladder,  and  excruciating 
pain;  a  mucous  discharge;  heat  and  throbbing  in  the  vulva,  with  constitutional 
disturbances  in  the  form  of  loss  of  appetite,  headache,  wakefulness,  etc. 

The  urethra  should  be  explored  under  ether,  the  growth  cut  away,  and  nitric 
acid  applied.  If  the  growth  is  flat,  and  non-pedicellated,  the  acid  will  suffice. 
Dr.  Jackson  has  devised  a  fenestrated  glass  speculum,  half  an  inch  in  diameter, 
with  which  to  examine  and  make  the  applications  in  these  cases.  In  using  nitric 
acid,  he  takes  a  little  dampened  cotton,  dips  it  in  fuming  acid,  and  applies  it  firmly 
against  the  spot  from  which  the  growth  has  been  cut  away  ;  or  upon  the  flat  patch 
of  disease,  for  at  least  a  minute.  Bleeding  can  be  arrested  by  simp1)-  rotating  the 
speculum  so  as  to  apply  the  closed  portion  over  the  exuding  surface. 

rlhe  Simpler  Varieties  of  Perineal  Laceration. — Dr.  Thaddeus  A.  Reamy, 
of  Cincinnati,  Ohio,  had  examined  600  cases  of  rupture  of  the  milder  types  in 
twelve  years;  421  superficial  of  fourchette  and  perineum;  and  179  rupture  to 
sphincter  ani.    He  draws  the  following  conclusions  from  these  cases,  viz.  :  — 

A.  "  Perineal  lacerations,  to  a  degree  of  importance  in  ultimate  results  at  least, 
are  far  more  common  than  is  generally  recognized  by  physicians  and  patients." 

B.  "No  form  of  laceration,  however  simple  in  degree,  heals  with  union  by 
first  intention  when  unaided  by  surgical  closure." 

C.  "  When  a  laceration  in  any  degree  heals  by  granulation,  it  necessarily  leaves 
cicatricial,  and  other  deformities." 

D.  "  Slight  perineal  lacerations  play  a  more  important  role  in  the  induction  of 
bodily  and  mental  disease  than  is  generally  recognized." 

E.  "  Since  a  perfect  cure  in  any  case  can  only  be  effected  by  surgical  closure 
of  the  torn  edges,  immediate  or  remote,  the  same  rules  should  apply  to  the  man- 
agement of  simple  cases,  as  to  severe  ones." 

F.  "It  would  follow  that  simple  cases  ought  generally  to  be  operated  on  at  the 
time  of  the  accident,  since  this  is  accepted  as  proper  for  severe  cases." 


1878.]    Liverpool  and  Manchester  Medical  and  Surgical  Reports. 


495 


G.  "  Cases  of  perineal  laceration  in  the  first  and  second  degree,  which  are  not 
closed  by  suture  primarily,  should  be  operated  upon  so  soon  as  any  of  the  symp- 
toms, physical  or  mental,  traceable  to  the  deformity  arise." 

In  not  one  of  the  600  cases,  all  healed,  was  the  union  by  the  first  intention. 

The  Menstrual  Cycle  is  the  title  of  a  paper  by  Dr.  John  Goodman,  of  Louis- 
ville, Kentucky.  The  period  of  time  that  elapses  between  the  successive 
appearances  of  the  menses  in  a  woman  who  claims  to  be  perfectly  regular,  is 
usually  set  down  as  twenty-eight  days.  Dr.  Goodman  made  a  series  of  observa- 
tions in  the  cases  of  41  women,  to  whom  he  gave  blanks  to  fill  up  ;  the  calcula- 
tions being  made  from  the  centre  of  one  epoch  to  the  next.  In  several  claiming 
perfect  regularity,  he  found  considerable  variation.  The  nearest  to  absolute  regu- 
larity ran  28,  26,  26,  28,  28,  28  days ;  but  a  fair  example  of  the  whole  gives  29, 
23,  25,  29,  32,  26  days,  as  the. consecutive  intervals.  The  general  mean  was 
27$  days,  the  exact  average  of  the  second  example  we  have  quoted.  A  low  but 
regular  average  is  given  in  Case  IV.  :  23,  23,  23,  20,  22,  23,  23;  mean  22f  ;  a 
series  of  long  intervals,  in  Case  XXVII.  :  31,  32,  40,  34,  41,  33,  31  ;  mean  34$. 

"The  length  of  the  cvcles  does  not  bear  any  fixed  relation  to  the  age  of  the 
individual."  R.  P.  H. 


Art.  XXI. — The  Liverpool  and  Manchester  Medical  and  Surgical  Reports. 
1877.  Edited  by  John  Wallace,  M.D.  8vo.  pp.  xvi.  244.  Liverpool: 
Adam  Holden,  1878. 

The  volume  before  us  might  have  been  considerably  reduced  in  size  with  ad- 
vantage to  the  reputation  of  its  editor  and  contributors.  Badly  bound,  contain- 
ing fourteen  articles,  some  of  them  of  indifferent  merit  and  all  disfigured  by  typo- 
graphical errors,  it  hardly  forms  an  issue  which  will  bring  any  great  credit  to  the 
parties  concerned  in  its  publication.  It  opens  with  a  long,  rambling,  loosely 
written  article  by  Hugh  Owen  Thomas  on  The  Past  and  Present  Treatment  of 
Intestinal  Obstruction,  which  hardly  presents  a  single  redeeming  feature  for  its 
58  pages  of  existence.  The  drift  of  his  paper  is  expressed  in  his  tenth  conclusion, 
when  he  states  "  That  there  are  only  two  indispensable  remedies  required  for  the 
treatment  of  these  difficulties  [i.e.,  intestinal  obstructions  from  whatever  source, 
with  the  sole  exception  of  a  loaded  rectum],  opium  and  gastro-enterotomy.  The 
former  is  indicated  in  every  case,  while  the  latter  is  required  when  symptoms 
show  that  the  former  must  fail."  The  character  of  his  essay  is  expressed  in  a 
statement  made  on  page  41,  where  he  refers  to  "  the  prevailing  fashion  in  nearly 
all  diseases  to  urge  the  use  of  what  are  mistermed  stimulants,  as  brandy,  wine, 
ammonia,  etc.  :  the  belief  in  their  stimulating  properties  being  based  upon  no 
better  premises  than  the  fact  of  the  one  being  pungent  to  drink,  and  the  other 
volatile  and  an  irritant  to  the  nostril." 

The  next  article  is  an  extremely  interesting  and  well- written  paper  by  James 
Ross,  M.D.,  M.R.C.P.,  entitled  Bacteria  not  essential  to  Infection.  Accepting 
as  the  first  proposition  in  his  argument  the  fact  that  the  bacteria  of  infective  fluids 
are  stated  to  belong  to  the  first  group  of  Cohn's  classification,  the  sphoero-bacteria 
or  micrococci  of  Hallier,  and  that  as  stated  by  Wagner  it  is  almost  impossible  to 
distinguish  these  bacteria  from  certain  granules  and  molecules  which  are  found  in 
the  higher  organisms  during  health,  the  author's  object  is  to  prove  that  the  so- 
called  bacteria  which  have  so  often  been  claimed  to  exist  in  infective  fluids  are 
not  bacteria  at  all,  but  free  granules  and  specks  of  protoplasm  derived  from  the 
disintegration  of  the  tissues  of  the  body.    In  support  of  this  view  he  states  that  in 


496 


Bibliographical  Notices. 


[Oct. 


the  central  contents  of  an  abscess  produced  by  injecting  three  minims  of  strong 
ammonia  into  a  frog's  thigh,  he  found  only  a  few  altered  red  blood  corpuscles 
with  scarcely  any  full  sized  white  cells,  the  corpuscles  present  being  with  varying 
intermediate  signs,  from  the  jqqg  to  the  y  5^5(5  of  an  inch  in  diameter.  These 
very  minute  particles,  which  he  maintains  have  often  been  mistaken  for  bacteria, 
were  very  numerous  and  active,  and  when  acetic  acid  was  added  resisted  its  action 
as  long  as  the  granules  of  the  larger  corpuscles,  and  that  when  the  protoplasm  was 
dissolved  from  these  cells,  the  resulting  granules  could  not  be  distinguished  from 
the  free  particles.  As  further  support  of  the  view  as  to  their  identity  he  men- 
tions that  the  lluid  taken  from  the  margins  of  the  abscess  contained  no  red  cells, 
a  greater  number  of  full-sized  white  cells,  and  fewer  free  granules,  the  variation 
being  interpreted  on  the  supposition  that  the  inflammation  had  been  much  less 
intense,  at  the  margins  of  the  abscess,  and  that  consequently  there  had  been  less 
disintegration.  The  author  further  states  that  the  morphological  elements  of  a 
pyaemic  abscess  are  of  the  same  character,  and  suggests  the  same  explanation  as 
to  their  formation  ;  corpuscles  less  in  size  than  in  healthy  pus  and  more  granular, 
and  a  large  number  of  free  particles  in  active  motion — Brownian  in  character — 
which  could  only  be  distinguished  from  bacteria  (sphoero-bacteria)  by  the  applica- 
tion of  chemical  tests,  proofs  which  he  claims  have  not  been  furnished  by  the  dis- 
coverers of  so-called  bacteria  in  infective  fluid.  In  addition  to  the  fact  that  these 
particles  cannot  be  distinguished  from  the  granules  imbedded  in  the  white  cor- 
puscles, instead  of  finding  an  accumulation  of  bacteria  in  the  capillaries  of  the 
body,  as  one  would  expect  under  the  germ  theory  were  these  particles  really 
independent  organisms,  the  appearances  found  are  very  different,  more  nearly 
resembling  those  of  tuberculosis  in  the- mesentery  of  the  lower  animals,  viz.,  an 
accumulation  of  a  large  number  of  white  corpuscles  surrounding  the  vessels.  Dr. 
Ross  applies  the  same  explanation  as  to  the  nature  of  the  particles  found  in  the 
desquamation  of  scarlet  fever,  the  so-called  vaccine  organisms  and  the  particles  of 
smallpox,  where,  although  numerous  free  granules  and  even  clusters  of  active 
granules  are  found,  no  undoubted  rod-bacteria  have  ever  been  detected  when  their 
presence  could  not  be  explained  as  having  been  introduced  from  external  germs. 

As  regards  the  organisms  which  Dr.  Klein  claims  to  have  discovered  in  the 
lymphatics  in  smallpox,  Dr.  Ross  shows  that  they  were  appearances  entirely  pro- 
duced through  his  method  of  manipulation,  and  were  not  organisms  at  all,  since 
he  has  frequently  seen  precisely  the  same  appearances  in  the  intestine  of  a  rabbit 
poisoned  with  a  vanadium  salt.  Added  to  the  arguments  drawn  from  the  mor- 
phology of  these  particles  as  to  the  probability  of  their  originating  from  the  dis- 
integration of  the  tissues  of  the  body,  the  author  shows  that  other  reasons  may 
be  drawn  from  a  consideration  of  their  function.  While  not  denying  that  the 
admission  of  these  bacteria  into  wounds,  etc.,  increases  the  danger  of  pyaemic 
infection,  and  therefore  he  admits  the  value  of  antiseptic  treatment,  he  claims, 
however,  that  this  new  element  of  danger  is  not  due  to  the  creation  of  a  parasitic 
disease,  but  simply  to  the  occurrence  of  septic  changes  in  the  contents  of  the 
abscess,  precisely  as  would  occur  in  any  other  putrescible  fluid  outside  of  the 
body ;  while  the  increased  infective  power  is  due  to  the  increased  inflammation 
and  disintegration  of  tissue — the  results  of  that  disintegration  being  themselves  the 
source  of  the  infection ;  so  placing  the  theory  of  pyaemic  infection  in  analogy 
with  the  infection  of  tuberculosis,  cancer,  and  other  pathological  tissues. 

As  proof  as  to  the  necessity  for  the  existence  of  some  other  element  over  and 
above  that  of  bacteria  in  order  to  constitute  an  infected  atmosphere,  he  alludes 
to  the  fact  that  an  albuminous  fluid  will  putrefy  and  contain  bacteria  nearly  as 
soon  in  pure  country  air  as  in  the  infected  ward  of  a  hospital,  while  there  is  no 


1878.]    Liverpool  and  Manchester  Medical  and  Surgical  Reports.  497 


such  comparison  between  the  results  of  surgical  cases  under  the  two  circum- 
stances. 

The  author's  position  is  further  strengthened  by  the  fact  that,  after  death  from 
erysipelas  and  peritonitis,  when  the  danger  of  infection  is  at  its  height,  the  blood 
is  crowded  with  these  granules,  the  so-called  micrococci,  while  no  true  bacteria 
exist,  while  after  putrefaction  sets  in,  and  true  organisms  appear  in  myriads,  the 
infective  power,  so  far.  from  increasing,  soon  disappears  altogether. 

The  foregoing  abstract  represents  the  views  advanced  by  Dr.  Ross  before  the 
meeting  of  the  British  Medical  Association  at  Sheffield  in  1876.  We  have  pre- 
sented them  somewhat  at  length  on  account  of  their  importance,  and  because  we 
have,  as  yet,  seen  no  attempt  at  their  refutation.  It  is  true,  as  Dr.  Ross  states 
in  the  supplement  to  his  paper,  that  the  statement  of  his  views  has  been  met  with 
the  assertion  of  contrary  views  by  "  competent  observers  ;"  but  this,  so  far  from 
weakening  his  position,  may  be  regarded  as  one  of  its  strongest  supports,  since, 
if  assertions  of  opinion  are  the  strongest  arguments  to  be  advanced  by  "compe- 
tent observers,"  it  is  to  be  presumed  that  incompetent  observers  can  advance  no 
stronger  arguments. 

That  infection  may  be  due  to  the  disintegration  of  the  white  corpuscles  appears 
to  be  confirmed  by  the  experiments  recently  made  by  Dr.  Kohler,  of  Dorpat, 
under  the  direction  of  Prof.  Schmidt.  He  found  that  symptoms  analogous  to 
those  of  septicemia  were  caused  by  the  injection  of  the  strained  fluid  from  a 
broken-up  clot  (the  formation  of  which  Dr.  Schmidt  has  shown  to  be  due  to  the 
results  of  the  disintegration  of  the  white  cells)  into  the  arterial  system  of  an  ani- 
mal, which  blood  had  been  drawn  only  twenty  minutes  before  from  the  arteries 
of  the  same  animal ;  it  is  true  that  Dr.  Kohler  states  that  bacteria  were  also  pre- 
sent, though  he  gives  no  explanation  as  to  their  source,  and  was  probably  misled 
by  the  appearances  alluded  to  by  Dr.  Ross.  Dr.  Sanderson  has  also  made  use 
of  these  experiments  in  support  of  his  own  views,  but  apparently  on  entirely  in- 
sufficient grounds.  In  the  supplement  to  his  paper,  Dr.  Ross  states  that  he  has 
watched  the  gradual  dissolution  of  the  protoplasm  of  a  pus-corpuscle,  and  the 
apparent  metamorphosis  of  the  granules  into  bacteria,  an  observation  analogous 
to  that  of  Dr.  Clark,  of  Boston,  who  noticed  the  apparent  formation  of  vibrios 
from  the  fibrillas  of  muscles,  though  he  explains  it  on  other  grounds  than  as  an 
instance  of  heterogenesis.    The  paper  is  illustrated  with  a  plate. 

The  next  fifteen  pages  of  the  report  are  occupied  with  an  account  of  Some 
Results  of  Lead  Impregnation,  by  Dr.  Shearer,  of  Liverpool,  consisting  of 
notes  of  six  cases,  which,  however,  present  no  very  unusual  features. 

We  come  next  to  an  article  on  Turning,  with  Notes  of  Forty  Cases,  iviih 
Remarks,  by  T.  H.  V.  Grosholtz,  L.K.  and  Q.C.P.,  etc.  Of  the  40  cases 
in  which  the  author  performed  version,  32,  or  four-fifths,  were  for  malpresenta- 
tion  of  the  foetus,  of  which  the  shoulder  presented  1 7  times ;  arm  and  funis,  7  ; 
arm,  3  ;  face  and  hand,  3  ;  brow,  1  ;  back,  1.  Of  the  remaining  eight,  3  cases 
were  on  account  of  pelvic  contraction,  3  for  placenta  praevia,  and  2  for  uterine 
inertia.  No  note  is  made  as  to  their  numerical  relation  to  normal  labours.  As 
to  the  results,  he  states  that  no  maternal  deaths  occurred,  and  that  eighteen 
children  were  either  born  dead  or  died  soon  after  birth.  Of  these  18,  7  are 
stated  to  have  been  dead  some  time,  as  shown  by  signs  of  putrefaction  ;  omitting 
these,  the  mortality  is  1  in  3.  Of  the  remaining  11  born  dead,  in  2  cases  there 
was  prolapse  of  the  funis,  1  placenta  prsevia,  "and  the  remaining  8  might  be 
roughly  classed  together  as  owing  their  death  to  a  disproportion  between  the  ma- 
ternal pelvis  and  the  infantile  cranium." 

The  next  paper  is  by  Mr.  J.  Dixon  Mann,  on  Chronic  Atrophic  Rhinitis. 
After  describing  the  prominent  features  of  the  disease,  he  publishes  the  notes  of 
No.  CLII  Oct.  1878.  32 


498 


Bibliographical  Notices. 


[Oct. 


our  cases,  of  which  one  was  the  sequence  of  traumatic  rhinitis ;  two  were  of 
syphilitic  origin,  and  one  followed  simple  nasal  catarrh  ;  in  all  of  these  the  appli- 
cation of  a  dilute  ointment  of  the  red  oxide  of  mercury  was  followed  by  beneficial 
results.  He  recommends  the  application  of  the  ointment  on  a  brush,  mounted  on 
a  curved  wire  handle,  for  the  posterior  nares  and  vault  of  pharynx.  When  the 
seat  of  the  disease  is  more  anterior,  the  bulb  of  a  small  olivary  bougie  may  be 
coated  with  ointment,  and  carried  up  to  the  seat  of  mischief,  avoiding  touching 
the  walls  of  the  passage  until  the  desired  locality  is  reached.  This  treatment 
should  be  employed  every  day  when  practicable,  or  at  least  three  times  a  week, 
several  applications  being  made  at  each  sitting ;  it  is  claimed  to  succeed  in  cases 
which  have  resisted  astringent  and  stimulating  douches,  atomized  fluids,  and  in- 
sufflated powders  of  various  kinds,  and  general  treatment.  In  the  syphilitic  cases 
general  specific  treatment  was  also  employed. 

As  Gleanings  from  Obstetric  Cases,  Mr.  J.  Armstrong  reports  a  case  of 
vaginal  haematoeele,  occurring  after  the  second  stage  of  labour,  and  a  case  of 
puerperal  septicaemia.  As  a  conclusion  from  the  sparse  clinical  notes  of  the 
latter,  the  author  states  "that  this  was  a  case  of  puerperal  septicaemia,  probably 
due  to  self-infection,  its  origin  being  a  foreign  body  retained  in  the  uterus,  which 
decomposed,  and  was  absorbed.  The  foreign  body  may  be  a  bit  of  placenta,  or 
membrane,  or  retained  coagula.  I  had  no  reason  to  think  it  could  be  any  of 
these.'"  He  also  concludes,  from  the  same  facts,  that  in  similar  cases,  the  ob- 
stetrician would  be  justified  in  attending  other  labour  cases,  provided  he  kept  his 
hands  clean ;  and  that  such  case  might  be  attended  in  a  lying-in  hospital  with 
impunity  to  the  other  patients,  provided  she  had  a  separate  nurse.  He  also  re- 
ports a  case  of  puerperal  eclampsia,  occurring  at  the  seventh  month  of  gestation, 
in  which  chloroform  was  used  successfully. 

Under  the  heading  of  Cases  from  Surgical  Practice,  Mr.  Andrew  Bont- 
flower  has  contributed  notes  of  two  successful  cases  of  ovariotomy,  and  a  de- 
scription of  a  ucav  method  of  operation  for  naevus.  As  Mr.  Bontilower  thinks 
that  one  difficulty  with  the  ordinary  clamp  in  cases  of  ovariotomy  is,  that  the 
pedicle  is  not  compressed  uniformly,  he  has  designed  one  which  he  thinks  will 
remedy  this  defect,  and  represents  it  in  a  drawing.  He  has  never,  as  yet,  used 
it.    His  method  of  operating  for  najvus  he  describes  as  follows  : — 

"I  passed  three  acupressure  pins  horizontally,  at  equal  distances,  and  parallel 
to  each  other.  After  puncturing  the  skin  with  the  point  of  the  pin.  I  passed  it 
on  in  a  rotatory  kind  of  way,  something  like  darning  a  stocking,  backwards  and 
forwards,  taking  care  to  keep  the  point  away  from  the  skin  and  mucous  mem- 
brane until  it  emerged  at  the  opposite  side  of  the  lip  ;  endeavouring  in  this  way  to 
secure  compression  of  all  the  veins,  and  at  the  same  time  to  include  them  all  in 
the  grasp  of  the  pin.  This,  I  believe,  would  have  been  sufficient,  but  in  order 
to  make  quite  certain,  I  passed  a  ligature  of  worsted,  in  a  figure-of-8  fashion, 
over  the  pin,  but  not  sufficiently  tight  to  impede  the  circulation  in  the  skin. 
The  worsted  was  allowed  to  remain  three  or  four  days,  but  the  pins  were  not  re- 
moved for  a  fortnight ;  the  parts  gradually  shrunk,  the  veins  became  obliterated, 
the  darkened,  purplish  skin  resumed  its  healthy  hue  without  any  cicatricial  marks : 
and  in  about  eight  weeks  the  lip  had  so  far  resumed  its  natural  size  and  shape 
that  it  would  have  been  difficult  to  trace  any  sign  of  the  nasvus." 

He  presents  the  likeness  of  another  case  operated  upon  in  the  same  manner,  in 
which,  judging  from  the  appearance  "before  and  after,"  the  success  was  equally 
as  good. 

Mr.  Richard  Caton  has  made  a  case  of  Plastic  Bronchitis  occurring  in  a 
boy  five  years  of  age  the  basis  of  a  communication  as  to  the  Pathology  of  this 
disease.  The  author  states  that  "owing  to  its  comparative  rarity,  no  very 
careful  investigation  has  yet  been  undertaken  of  its  pathology.    The  last  impor- 


1878.]    Liverpool  and  Manchester  Medical  and  Surgical  Reports.  499 


tant  paper  which  has  appeared  on  the  subject  in  the  English  journals,  is  one  pub- 
lished by  Dr.  Peacock  in  the  Pathological  Transactions  in  1854."  If  we 
accept  this  statement  as  true  previous  to  the  writing  of  Dr.  Caton's  article,  we 
are  warranted  in  considering  its  truth  more  decidedly  established  now.  The 
paper  is  illustrated  by  a  lithograph. 

Mr.  Francis  Vacher  has  published  a  11  Note  on  an  Improvement  in  the  short 
hinged  Forceps,"  as  an  addition  to  his  other  improvements  detailed  in  the  volume 
of  these  Reports  for  1874. 

As  illustrations  of  the  "Value  of  Venesection,"  Mr.  T.  R.  Glynn  has  re- 
ported several  cases  of  bronchitis  and  heart  disease  and  one  case  of  renal  disease 
with  uraemia  in  which  blood-letting  appears  to  have  been  of  some  service.  Among 
the  "  Remarks"  it  appears  that  "  it  would  be  quite  possible  to  diagnose  cases  of 
bad  bronchitis  and  emphysema  by  the  nose  alone,  from  the  fumes  of  brandy  and 
ether  which  generally  surround  them." 

Following  the  above  communication  is  a  long  and  well  written  article  by  Dr. 
E.  H.  Dickinson  on  "The  Phenomena  of  so-called  Direct  Paralysis."  Instead 
of  taking  the  ground,  as  has  lately  been  done  elsewhere  in  England,  that  because 
these  cases  do  not  accord  with  preconceived  notions,  therefore  the  data  of  obser- 
vations themselves  are  false,  Dr.  D.  reports  with  great  elaboration  of  detail  and 
after  the  careful  consideration  and  refutation  of  every  argument  which  could  be 
urged  against  its  acceptance  as  such,  a  case  which  would  establish  conclusively,  if 
such  confirmation  were  needed,  the  existence  at  least  of  a  class  of  cases  in  which 
the  paralysis  occurs  in  and  is  confined  to  the  side  of  the  body  corresponding  to 
the  lesion  in  the  brain.  After  alluding  to  the  various  more  or  less  weak  hypothe- 
ses which  have  been  proposed  by  Bennett,  Copland,  Longet,  Bastian,  SchifF,  and 
Ferrier  as  attempts  at  explaining  these  cases,  the  author  considers  more  at  length 
the  theory  advocated  by  Brown- S6quard,  though  creating  the  impression  of  not 
having  entirely  appreciated  the  force  of  some  of  that  author's  arguments.  For 
example,  he  has  interpreted  his  statement  that  "it  is  not  possible  to  look  upon 
paralysis  in  cases  of  brain  disease  as  being  the  effect  of  loss  of  function  of  the  part 
diseased"  (i.  e.,  conductors  or  centres  employed  by  the  will  in  the  production  of 
motion),  as  meaning  that  "  the  character  of  the  symptoms  in  the  brain  is  in  no 
way  dependent  on  the  seat  of  the  lesion," — an  interpretation  certainly  not  war- 
ranted by  the  views  advanced  by  Dr.  Brown- S6quard  in  this  country  last  winter 
(see  Med.  Record),  where  he  gave  such  precise  guides  for  recognizing  the  seat  of 
lesion.  The  impression  generally  conveyed  by  the  statement  above  alluded  to 
seems  to  be  "  that  paralysis  cannot  be  explained  as  due  to  the  interruption  of 
conduction  of  motor  impulses,  for,  according  to  such  an  anatomical  explanation, 
the  same  anatomical  cause  should  invariably  be  followed  by  the  same  effect,  one 
such  exception  should  be  enough  to  overthrow  this  explanation."  As  regards 
Dr.  Brown-  Sequard's  explanation  as  to  the  production  of  paralysis  through 
"irritation,"  Dr.  Dickinson  thinks  that  this  view  is  the  only  one  which  will  sat- 
isfy the  conditions  of  "direct  paralysis,"  though  he  thinks  that  its  acceptance 
should  not  entail  the  abandonment  of  our  views  as  to  the  mode  of  production  of 
the  much  more  numerous  cases  of  crossed  paralysis.  In  other  words,  Dr.  D. 
occupies  a  conservative,  half-way  position,  in  which,  while  still  holding  the  doc- 
trine of  a  physiological  crossing  of  motor  paths  in  the  medulla  and  the  ordinary 
causation  of  paralysis  through  interruption  of  motor  conduction,  he  accepts  the 
"irritative"  origin  of  the  "direct"  form  of  paralysis,  though,  however,  even  in 
these  instances  he  clings  to  the  decussation,  holding  that  the  irritation  is  transfer- 
red to  the  side  of  the  brain  opposite  the  lesion,  and  then  produces  a  crossed  para- 
lysis as  it  always  used  to  do. 

Following  this  is  a  paper  entitled  A  Plea  for  the  more  free  removal  of  Can- 


500 


Bibliographical  Notices. 


roct. 


cerous  Groivths',  by  W.  Mitchell  Banks,  F.R.C.P.,  and  the  notes  of  Four 
Cases  of  Antiseptic  Osteotomy,  by  W.  M.  Campbell,  M.D.,  M.R.C.S. 

The  remaining  thirty  pages  of  the  volume  are  occupied  by  an  abstract  of  the 
proceedings  of  the  Liverpool  Medical  Society,  for  the  session  of  1875-6,  consist- 
ing, apparently,  of  an  enumeration  of  the  cases  of  its  members, — cases  for  the 
most  part  utterly  commonplace  in  character,  while  those  which  might  otherwise 
have  proved  of  interest  are  entirely  lost  through  their  meagreness  of  detail. 

II.  M.  S. 


Art.  XXIT. — A  Monograph  of  Two  Hundred  and  Forty-eight  Cases  of  Late- 
ral Lithotomy  Operations.  By  Rai  Ram  Naraix  ])ass  Bahadoor,  Lec- 
turer on  Surgery  in  the  Campbell  Medical  School,  and  First  Surgeon  to  the 
Campbell  Hospital,  Calcutta.  8vo.  pp.  90.  Calcutta :  Thacker,  Spink  & 
Co.,  187G. 

If,  contrary  to  the  astronomical  views  and  opinions  of  the  Rev.  Mr.  Jasper, 
as  recently  announced  from  the  pulpits  of  Richmond  and  other  cities,  the  sun  do 
not  move,  certain  it  is  that  this  world  of  ours  does,  and  it  is  safe  to  say  that  it 
never  moved  more  rapidly  than  it  does  at  the  present  moment.  Education, 
general  and  special,  the  arts  and  sciences,  manufactures,  commerce,  all  kinds  of 
discoveries  and  improvements,  are  moving  on  with  a  degree  of  velocity  alike 
astonishing  and  gratifying.  Man,  although  he  has  only  five  senses,  is,  neverthe- 
less, a  wonderful  being,  endowed  with  resistless  industry,  vast  ambition,  and  a 
genius  which  enables  him  to  penetrate  the  most  profound  mysteries  of  nature. 
Civilization  is  rapidly  extending  its  influence,  and  the  day  is  not  distant  when 
substantial  contributions,  in  the  various  branches  of  human  knowledge,  will  be 
made  to  our  stock  of  information  by  various  nations  of  the  earth  at  present  in  a 
state  of  semi-barbarism,  or  still  steeped  in  Cimmerian  darkness.  The  natives  of 
India  and  Japan  are  rapidly  adopting  our  language,  and  the  habits,  education, 
modes  of  life,  and  even,  at  least  in  part,  the  religion  of  America  and  Europe. 
China,  too,  is  making  more  or  less  progress  in  these  directions,  and  it  cannot  be 
long  before  Africa  will  take  up  the  march.  Wherever  commerce  and  religion 
penetrate,  civilization  is  sure  to  exert  her  influence,  and  to  open  new  sources  of 
knowledge,  wealth,  and  enterprise.  No  one,  even  the  most  sanguine,  can  pre- 
dict what  the  next  quarter  of  a  century  may  bring  forth  ;  we  live  in  an  age  the 
most  wonderful  the  world  has  ever  seen ;  the  earth  is  full  of  knowledge,  and  the 
telegraph,  the  telephone,  and  the  steam-engine  have  literally  annihilated  time  and 
space. 

Such  thoughts  as  these  naturally  suggest  themselves  to  one  engaged  in  perusing 
the  work  of  a  native  of  India,  who,  under  the  influence  of  an  English  education, 
has  attained  a  most  enviable  rank  as  a  surgical  teacher,  lithotomist,  and  prac- 
titioner. Mr.  Rai  Ram  Narain  Dass,  the  author  of  the  monograph  whose  title 
heads  this  article,  has  gradually  worked  his  way  up  from  the  most  humble  to  the 
highest  position  in  his  profession.  As  a  student  he  was  greatly  distinguished  for 
his  zeal  and  industry  in  the  acquisition  of  knowledge,  es-pecially  in  surgical 
science  and  in  analytical  chemistry,  in  the  latter  of  which  he  took  one  of  the 
prizes  at  the  annual  examinations.  After  having  been  for  some  time  in  charge 
of  the  Cawnpore  Government  Dispensary,  and  of  the  Civil  Station  of  Budaon, 
Lecturer  on  Surgery  to  the  Bengalee  and  Military  Classes  of  the  Medical  College 
of  Bengal,  and  one  of  the  House  Surgeons  to  the  Fever  Hospital,  he  was  trans- 
ferred to  Calcutta,  where  he  has  for  years  filled  the  chair  of  Surgery  in  the 


1878.]  Eai  Ram  Xaraix  Dass,  Lateral  Lithotomy  Operations.  501 


Campbell  Medical  College,  and  the  office  of  first  Surgeon  to  the  Campbell  Hos- 
pital. After  a  brilliant  career  of  nearly  forty  years,  during  which,  as  a  teacher 
and  a  successful  practitioner,  he  has  conferred  vast  benefits  upon  his  countrymen, 
he  is  about  to  retire  from  the  active  duties  of  his  profession,  in  the  expectation  of 
obtaining  a  pension  from  the  British  Government  to  solace  his  declining  years, 
his  pay  as  a  public  officer  having  always  been  very  limited,  never  exceeding  three 
hundred  and  fifty  rupees  a  month.  As  a  lithotomist"  his  success  has  been  extraor- 
dinary. Of  248  cases  of  lateral  lithotomy,  performed  in  the  Northwestern 
Provinces  of  India  during  a  period  of  twelve  years,  only  17,  or  1  in  \4-k,  died. 
For  many  years  he  has  been  a  teacher  of  the  native  pupils  in  the  Calcutta 
Medical  College,  and  it  is  due  to  him  to  say  that  he  has  done  more  than  any 
other  man  in  diffusing  surgical  knowledge  through  that  widely  extended  country. 
In  1869,  the  title  of  "Bahadoor"  was  conferred  upon  him  in  consideration  of 
his  distinguished  services;  and,  in  1876,  he  received  from  the  Empress  of  India 
a  certificate  in  recognition  of  his  position  as  a  distinguished  medical  practitioner. 

The  work  of  Mr.  Eai  Earn  Narain  Dass  is  based  essentially  upon  personal  ex- 
perience, or  upon  what  he  himself  saw  and  did  during  a  period  of  more  than  a 
third  of  a  century  in  a  country  in  which  stone  in  the  bladder  is  of  uncommon 
frequency.  After  some  brief  introductory  remarks,  and  the  history  of  some 
unusual  cases,  the  author  treats  of  the  etiology  of  calculous  affections,  and  then 
gives  a  graphic  account  of  the  operative  part  of  the  subject,  winding  up  with  a 
tabular  view  of  220  cases  of  lithotomy,  and  an  account  of  the  chemical  analysis 
of  128  stones,  accompanied,  in  every  instance,  by  a  lithographic  illustration  of 
their  external  and  internal  characters.  The  labour  bestowed  upon  this  portion  of 
the  work  can  be  better  imagined  than  described.  It  must  simply  have  been  im- 
mense. To  render  the  investigations  more  complete,  the  microscope  was  inva- 
riably used.  It  is  a  remarkable  fact  that  not  one  of  the  calculi  examined  was 
found  to  be  simple  in  character  ;  on  the  contrary,  every  one  was  composed  of  two 
or  three  substances,  which  were  generally  of  an  organic  nature,  such  as  uric  acid 
and  urate  of  ammonia,  and  which  almost  invariably  formed  the  basis  of  every 
nucleus.  Inorganic  substances,  such  as  phosphates  and  oxalates,  entered  into  the 
composition  of  the  outer  layer,  but  only  in  a  few  instances  into  that  of  the  nucleus, 
and  then  always  in  combination  with  organic  elements.  Calculi  of  phosphate  ot 
lime  or  bone  earth  would  seem  to  be  very  rare  in  India,  as  no  specimen  entirely 
composed  of  this  substance  was  found  in  the  author's  collection.  It  was,  how- 
ever, frequently  detected  in  union  with  phosphate  of  magnesia  and  ammonia,  or 
what  is  known  as  the  triple  phosphate.  None  of  the  calculi  examined  consisted 
of  pure  oxalate  of  lime;  and  cystic  oxide,  or  cystine,  was  found  only  in  four 
specimens,  in  traces  in  combination  with  urate  of  ammonia  and  phosphate  of 
lime.  It  is  proper  to  add  that  the  author,  in  every  instance,  gives  the  date  of 
the  operation,  and  everything  of  interest  or  value  relative  to  the  physical  and 
chemical  characters  of  the  concretions.  There  is  no  such  thorough  account  of 
these  matters,  so  far  as  the  writer's  information  extends,  in  any  other  work. 

The  etiology  of  stone  has  long  been  a  subject  of  deep  interest.  It  is  very 
briefly  discussed  by  our  author.  Of  220  cases  of  stone  operated  upon  at  the 
Budaon  Government  Dispensary  between  April,  1847,  and  May,  1852,  30  were 
Mussulmans,  and  190  were  Hindoos;  or  in  the  ratio  of  1  to  6.  This  difference 
in  the  liability  to  this  disease  in  the  two  castes,  the  author  thinks,  is  mainly  due 
to  the  difference  in  the  nature  and  character  of  their  food.  The  Hindoos  live 
principally  upon  vegetables,  which,  in  the  Northwestern  Provinces,  where  the 
complaint  is  most  prevalent,  are  generally  eaten  raw  ;  a  circumstance  which  pre- 
disposes to  indigestion,  and  to  the  formation  of  acid  in  the  alimentary  canal.  As 
a  consequence  of  these  disorders  the  urine  is  constantly  surcharged  with  acid,  the 


502 


Bibliographical  Notices. 


[Oct. 


skin  becomes  inactive,  and  the  kidneys  are  compelled  to  eliminate,  as  best  they 
can,  the  nitrogenous  substances  thrown  off  by  the  metamorphosis  of  the  living 
tissues,  in  the  form  of  uric  acid  and  urea.  The  author  states  that  the  water  in  the 
localities  in  which  calculous  affections  are  most  frequent,  is  strongly  impregnated 
with  calcareous  matter,  but  he  has  not  been  able  to  trace  any  direct  agency  from 
this  source  upon  the  production  of  stone  in  the  bladder.  Geological  peculiarities 
and  climate,  especially  the  latter,  probably  exercise  some  influence  on  the  origin 
of  the  complaint.  "  The  disease  is  particularly  common  throughout  Rohilkund, 
and  especially  in  the  stony  and  sandy  districts.  The  temperature  of  these  dis- 
tricts is  exceedingly  high,  and  consequently  the  atmosphere  is  rarefied,  and  the 
oxygenating  processes  of  respiration  are  correspondingly  imperfect ;  more  work 
is  thrown  upon  the  kidneys,  and  the  excretion  of  urea  and  uric  acid  is  increased. 
Moreover,  the  variations  of  temperature  are  great,  and  the  functions  of  the  skin 
are  therefore  being  constantly  interfered  with,  and  additional  work  is  thrown 
upon  the  kidneys.  Probably,  therefore,  a  variety  of  predisposing  causes,  indi- 
gestible food,  drinking  calcareous  water,  and  climatic  and  geological  local  condi- 
tions, explain  the  fact  that  vesical  calculous  diseases  are  found  to  be  as  common 
among  the  people  in  the  sandy  and  stony  districts  of  the  Northwestern  Provinces 
as  elephantiasis  is  in  Bengal."  In  one  case,  in  which  a  stone  was  extracted  from 
a  Mussulman  who  had  lived  on  an  exclusively  animal  diet  from  his  earliest  in- 
fancy, the  malady  was  doubtless  caused  by  an  excess  of  nitrogenous  matter  in  the 
system.  Calculous  disease  is  most  prevalent  among  children  from  two  to  ten 
years  of  age,  particularly  among  the  ill  fed  and  badly  clothed. 

"  Patients  whose  stones  are  composed  of  phosphate  and  triple  phosphate,  or 
even  merely  coated  with  these  salts,  are  usually  thin,  emaciated-looking  subjects, 
with  health  much  impaired,  and  symptoms  which  are  very  agonizing;  they  suffer 
more  after  their  operations  and  are  longer  in  getting  well ;  their  urine  is  always 
ammoniacal  from  the  decomposition  of  urea.  In  the  specimens  of  calculi  I 
examined  I  found  no  stone  composed  exclusively  of  triple  phosphate  or  phosphate, 
but  I  found  these  salts  variously  mixed  with  uric  acid  and  urate  of  ammonia  ;  in 
none  of  the  specimens  was  the  nucleus  found  to  be  composed  of  phosphate  and 
triple  phosphate. 

"'Among  the  specimens  of  stones  examined,  not  one  was  found  to  be  purely  of 
the  mulberry  kind,  but  the  oxalate  of  lime  was  found  to  be  variously  mixed  with 
uric  acid  and  urate  of  ammonia  :  the  symptoms  of  the  stone  in  these  cases  were 
very  agonizing,  but  they  were  not  generally  emaciated-looking  subjects ;  they 
were  usually  of  middle  age,  and  after  the  operation  they  got  well  rapidly  without 
much  suffering.  It  was  often  found  that  these  patients  were  more  afraid  of  submit- 
ting to  the  operation  than  others,  labouring  as  they  usually  did  under  great  nervous 
depression,  a  common  accompaniment  of  oxaluria ;  this  nervous  depression  may 
even  be  the  cause  of  morbid  action  leading  to  oxidation  of  a  portion  of  urea  and 
formation  of  oxalic  acid,  the  oxygen  being  derived  either  from  the  metamorphosis 
of  the  living  tissues  or  from  increased  activity  of  the  respiratory  organs. 

' '  After  carefully  examining  my  collection  of  calculi  I  find  that  most  of  the 
small-sized  stones  are  composed  of  uric  acid  and  urate  of  ammonia,  variously 
mixed  with  each  other  in  the  nucleus,  as  well  as  in  the  surrounding  laminae  ;  a 
very  limited  number  of  calculi,  besides  the  uric  acid  and  urate  of  ammonia,  con- 
tain traces  of  phosphate  of  lime,  oxalate  of  lime,  and  triple  phosphate  of  mag- 
nesia and  ammonia." 

The  operation,  as  performed  by  Mr.  Rai  Ram  Narain  Dass,  presents  nothing 
peculiar,  excepting  that,  in  dividing  the  deep-seated  structures  of  the  perineum, 
he  takes  the  staff  out  of  the. assistant's  hand,  and  depressing  the  handle  to  a  level 
with  the  axis  of  the  pelvis,  completes  the  cutting  part  of  the  operation.  The 
object  in  depressing  the  staff  is  to  render  the  bladder  tense,  and  so  facilitate  the 
division  of  the  resisting  tissues.  The  deep  incision  is  made  strictly  in  the  line  of 
the  external  one,  and  should  not  be  larger  than  is  absolutely  necessary  for  the 


1878.]    Ziemssen,  Cyclopaedia  of  the  Practice  of  Medicine.  503 


easy  extraction  of  the  calculus.  Mr.  Rai  Ram  Narain  Dass  deprecates  every- 
thing like  laceration  of  the  tissues ;  hence  he  always  uses  a  probe-pointed  bistoury 
to  effect  their  division,  if,  after  the  removal  of  the  staff,  they  are  found  to  offer 
undue  resistance.  The  stone  being  removed,  and  the  bladder  washed  out,  a 
female  catheter  or  gum-elastic  tube  is  inserted  in  the  wound  to  conduct  off  the 
urine,  retention  being  maintained  for  twenty-four  hours  in  the  child,  and  for 
forty-eight  hours  in  the  adult.  When  the  stone  is  uncommonly  large,  or  very 
difficult  of  extraction,  Mr.  Dass  does  not  hesitate  to  extend  the  incision  into  the 
anus,  or  even  into  the  rectum ;  and,  under  such  circumstances,  he  takes  special 
pains  to  wash  out  the  wound  every  second  hour  with  tepid  water,  to  prevent  the 
lodgment  of  fecal  matter  in  the  bladder.  Under  this  management  the  wound 
rapidly  heals,  leaving,  perhaps,  merely  a  small  recto- vesical  fistule,  which  event- 
ually disappears  under  the  occasional  application  of  caustic.  He  has  never  lost 
any  patient  from  hemorrhage,  or  urinary  infiltration  ;  nor  has  he  ever  met  with 
an  adherent  stone,  or  a  stone  surrounded  by  a  false  membrane,  the  result  of 
plastic  deposit. 

It  has  been  already  seen  that  the  success  of  our  author  has  been  most  extraor- 
dinary, the  mortality  in  the  248  cases  being  only  17,  or  in  the  ratio  of  1  to  14£. 
The  death-rate  in  children  from  two  to  ten  years  was  1  in  28  ;  from  ten  to  twenty, 
1  in  13^  ;  from  twenty  to  thirty  none  died  ;  but  from  this  period  on  the  mortality 
strikingly  increased,  so  that  the  death-rate  from  thirty  to  forty  was  1  in  10^- ;  from 
forty  to  fifty,  1  in  7  ;  and  from  fifty  to  sixty,  1  in  2^.  One  patient  operated 
upon  after  sixty,  recovered ;  and  one  after  seventy,  died.  If  we  compare  the 
results  of  these  operations  with  those  of  other  lithotomists,  they  will  be  found  to 
be  eminently  flattering  to  the  skill,  care,  and  judgment  of  Mr.  Rai  Ram  Narain 
Dass.  Cheselden,  the  greatest  lithotomist  of  his  day,  lost  20  cases  out  of  213  ; 
and  Liston,  another  great  surgeon,  16  out  of  115.  Guersant,  at  the  Hopital  des 
Enfans,  Paris,  cut  60  children,  with  a  loss  of  9.  The  alleged  success  of  Dudley, 
who  is  said  to  have  lost  only  6  cases  out  of  207,  is  exceedingly  problematical,  as, 
it  is  well  known,  he  kept  no  record  of  his  operations,  and  hence  could  only  guess 
at  an  approximate  result. 

We  thank  Surgeon  Dass  for  the  pleasure  and  instruction  we  have  derived  from 
a  perusal  of  his  interesting  and  valuable  monograph ;  and,  although  he  is  no 
longer  young,  we  shall  look  for  other  contributions  from  his  pen  in  other  fields 
of  surgery,  embodying,  as  this  does,  the  results  of  his  large  experience. 

S.  D.  G. " 


Art.  XXIII. — Cyclopaedia  of  the  Practice  of  Medicine.  Edited  by  Dr.  H. 
Von  Ziemssen.  Vol.  XIV. — Diseases  of  the  Nervous  System  and  Disturb- 
ances of  Speech.  By  Prof.  A.  Eulenburg,  of  Greifswald;  Prof.  H.  Noth- 
nagel,  of  Jena ;  Prof.  H.  Von  Ziemssen,  of  Munich ;  Prof.  F.  Jolly,  of 
Strasburg ;  Prof.  A.  Kussmaul,  of  Strasburg ;  and  Dr.  J.  Bauer,  of 
Munich.  Albert  H.  Buck,  M.D.,  of  New  York,  editor  of  American  edi- 
tion.   8vo.  pp.  xx.,  893.    New  York  :  William  Wood  &  Co.,  1877. 

The  diseases  of  the  nervous  system  form  a  class  which  probably  occasions  more 
embarrassment  to  the  average  practitioner  of  medicine  than  any  other.  And  this 
is  true  not  only  of  then  treatment  but  also  as  respects  their  diagnosis.  Symptoms 
presenting  a  close  resemblance  may  spring  from  very  different  lesions,  a  fact 
which  is  illustrated  by  paralysis  agitans  and  insular  sclerosis  ;  no  one  having  noticed 
that  the  trembling  in  the  latter  disease  only  attended  voluntary  movements  until 


504 


Bibliographical  Notices. 


[Oct. 


Charcot  pointed  out  the  fact.  This  is  only  one  of  the  many  instances  which  might 
be  adduced  to  show  the  difficulties  which  surround  the  differentiation  of  nervous 
disease  and  the  valuable  additions  which  recent  observers  have  made  to  our  knowl- 
edge of  the  pathology  of  the  nervous  system.  Since  none  of  the  text-books  in 
general  use  at  the  present  time  treats  of  nervous  diseases  with  anything  like  the 
same  detail,  the  volume  really  supplies  a  want ;  and  since  most  of  the  contributors 
are  identified  with  the  subjects  they  have  written  of  and  are  probably  known  by 
reputation  to  our  readers,  it  is  scarcely  necessary  to  add  that  it  does  this  well. 

To  Eulenberg  has  been  committed  the  task  of  describing  the  vaso-motor  and 
trophic  neuroses,  which  include  hemicrania,  angina  pectoris,  the  so-called  Base- 
dow's disease,  progressive  muscular  atrophy,  pseudo-hypertrophy  of  the  muscles, 
true  muscular  hypertrophy,  and  unilateral  progressive  atrophy  of  the  face.  The 
two  theories  which  have  been  thought  to  explain  most  satisfactorily  the  phenomena 
of  hemicrania  are  those  of  l)u  Bois  Revmond  and  Moellendorff.  The  former  ob- 
server, it  will  be  remembered,  assumed  that  certain  forms  of  migraine  were  caused 
by  a  unilateral  tetanus  of  the  vessels  of  the  head,  or  tetanus  in  the  district  supplied 
by  the  cervical  sympathetic.  The  latter,  on  the  other  hand,  attributed  the  pain  to 
a  unilateral  relaxation  of  the  vessels  of  the  head,  from  want  of  energy  of  the  vaso- 
motor nerves.  The  author  believes,  however,  that  neither  of  these  theories  is 
entirely  correct,  while  they  are  both  partially  so,  or,  in  other  words,  that  local 
anomalies  of  circulation  in  the  brain,  without  regard  to  their  special  mode  of  origin, 
are  to  be  regarded  as  the  essential  and  universal  causal  condition,  while,  on  the 
other  hand,  tetanus  or  relaxation  of  the  muscles  of  the  vessels  exercises  rather  an 
indirect  influence,  confined  to  single  cases,  and  acting  through  the  local  amemia 
or  hyperemia  of  which  it  is  an  important  cause.  The  classes  of  cases  in  which 
there  is  tetanus  of  the  vessels  he  distinguishes  as  hemicrania  sympathico-tonica  ; 
that  in  which  there  is  relaxation  as  hemicrania  angio-paralytica,  a  distinction 
which  he  holds  is  not  without  its  value  in  therapeutics. 

When  we  turn,  however,  to  the  treatment  of  this  disease,  we  do  not  find  as 
many  suggestions  as  we  had  hoped.  Caffein,  arsenic,  bromide  of  potassium,  iron, 
and  quinia,  especially  in  the  angio-paraly  tic  form,  are  among  the  remedies  recom- 
mended. In  the  angio-paraly  tic  form,  the  author  has  also  obtained  very  good 
results  from  the  use  of  ergotin.  On  the  other  hand,  in  the  sympathico-tonic,  tem- 
porary relief  seems  to  have  been  procured  in  some  cases  by  the  inhalation  of  nitrite 
of  amyl.  He  attributes  more  influence  to  the  constant  current  in  relieving  the 
symptoms  of  the  disease.  Indeed  in  some  cases  he  believes  that  it  is  able  to  effect 
a  permanent  cure.  In  hemicrania  sympathico-tonica  the  positive  pole  is  placed 
upon  the  cervical  portion  of  the  sympathetic,  at  the  inner  edge  of  the  sterno- 
cleido-mastoid  muscle,  the  other  one  is  placed  on  the  palm  of  the  hand  and  the 
circuit  closed.  In  the  other  form  the  position  of  the  poles  is  reversed,  and  he 
directs  that  the  current  shall  not  only  be  suddenly  closed  in  the  metallic  part  of 
the  circuit,  but  shall  be  made  to  produce  a  powerful  excitation  by  means  of 
repeated  closures  and  openings,  or  in  some  cases  by  reversals.  It  is  generally  con- 
ceded that  the  induced  current  exercises  no  beneficial  influence  upon  the  course 
of  migraine. 

Dr.  Eulenburg  allows  his  patriotic  feeling  to  get  the  better  of  his  judgment 
when  he  assigns  to  Basedow  the  credit  of  having  first  accurately  described  the  dis- 
ease which  in  Germany  is  generally  coupled  with  his  name.  Leaving  out  of  con- 
sideration the  fact  that  Flajani,  a  Roman  physician,  reported  in  1802  three  cases 
in  which  he  calls  attention  to  two  of  the  most  important  of  the  symptoms,  the 
enlargement  of  the  thyroid  gland  and  the  palpitation  of  the  heart ;  and  that  Parry 
in  1825,  in  a  group  of  cases  which  he  reports,  describes  one  in  which  in  addition  to 
these  symptoms  there  was  prominence  of  the  eyeballs,  the  prior  claims  of  that 


1878.]     Ziemssen,  Cyclopeedia  of  the  Practice  of  Medicine.  505 


great  clinical  teacher,  Graves,  of  Dublin,  ought  not  to  be  overlooked,  for  he 
appears  to  have  called  attention  in  his  lectures  to  all  the  leading  features  of  the 
disease  as  early  as  1835,  while  Basedow's  paper  was  not  published  until  1840. 

The  author,  while  admitting  that  the  theory  which  refers  all  the  symptoms  of 
the  disease  to  a  primary  affection  of  the  sympathetic  is  very  tempting,  and  that 
this  theory  is  sustained  by  the  results  of  post-mortem  examinations  in  certain  cases, 
says  that  it  cannot  be  accepted  unhesitatingly,  inasmuch  as  certain  of  the  symptoms 
are  such  as  are  commonly  supposed  to  follow  experimental  section,  or  paralysis  of 
the  nerve  ;  while  others,  on  the  contrary,  might  be  caused  by  galvanization,  and 
may  be  presumed  to  indicate  a  permanent  condition  of  irritation.  This  difficulty 
would  certainly  be  removed  if  Benedikt's  assumption  could  be  established  which 
refers  the  struma  to  an  active  irritation  of  dilator  nerves  which  run  in  the  sympa- 
thetic. There  would  remain,  however,  a  second  objection  which  lies  in  the  dif- 
ficulty of  conceiving  of  a  permanent  state  of  irritation  continued  for  years  together. 

In  addition  to  the  remedies  in  general  use  in  the  treatment  of  this  disease,  Dr. 
Eulenburg  recommends  galvanization  of  the  cervical  sympathetic  with  the  con- 
stant current.  This  agent  has,  he  says,  in  the  hands  of  Von  Dusch  not  only  reduced 
the  rate  of  the  pulse  from  130  to  70  or  64  beats,  but  also  brought  about  a  diminu- 
tion in  the  prominence  of  the  eyes. 

The  article  on  epilepsy  is  by  Prof.  Nothnagel,  of  Jena,  who  treats  of  the  sub- 
ject at  considerable  length.  He  excludes  from  the  category  of  epilepsy,  as  indeed 
do  all  the  principal  writers  on  nervous  diseases,  all  cases  of  ursemic  seizures,  and 
all  epileptiform  convulsions  in  which  demonstrable  gross  alterations  exist  in  the 
cranial  cavity,  the  effect  of  which  taken  altogether  may  be  comprised  in  this,  that 
they  either  directly  or  by  simple  mechanical  conditions,  occasion  an  angemia  of  the 
brain  substance.  On  the  other  hand,  in  opposition  to  Reynolds,  he  maintains 
that  the  form  of  reflex  epilepsy  ought  to  be  maintained.  It  is  a  well-established 
fac  t,  he  says,  that  in  persons  who  have  become  subject  to  epileptiform  seizures  as 
a  result  of  a  cicatrix  or  some  such  cause,  these  seizures  do  not  occur  only  or  ex- 
clusively after  irritations  of  the  cicatrix,  but  also  quite  spontaneously  or  after 
mental  changes.  The  former  would  necessarily  be  the  case  if  we  had  to  do  with 
reflex  manifestations,  and  therefore  we  must  assume  that  in  these  cases  a  peculiar 
change  has  taken  place  in  the  medulla  oblongata.  The  fact,  he  continues,  that 
recoveries  take  place  after  removal  of  the  irritation,  cannot  be  cited  as  disproving 
this  view,  for  they  generally  occur  only  in  cases  which  come  under  treatment 
soon,  and  in  which  therefore  the  epileptic  change  has  not  yet  became  inveterate. 
Finally,  it  does  not  favour  the  idea  of  simple  reflex  convulsions  that  (except  in  the 
case  of  wounds  of  the  head)  the  first  paroxysm  follows  only  a  considerable  time, 
perhaps  a  week,  after  the  establishment  of  the  peripheral  irritation.  He  thinks, 
however,  it  would  be  better  to  designate  as  secondary  epilepsy,  rather  than  reflex, 
all  those  cases  in  which  an  affection  of  the  brain,  the  spinal  cord,  or  the  peripheral 
nerves  is  present  as  a  source  of  excitement  and  a  starting  point  for  the  disease,  as 
this  name  commits  us  to  no  theory.  The  author  further  regards  as  epileptic  not 
merely  those  attacks  in  which  there  is  complete  loss  of  consciousness  without  mus- 
cular spasm,  generally  known  as  petit  mal,  but  also  those  which  are  marked  only 
by  simple  dizziness,  or  in  fact  by  any  alteration  whatever  of  the  mental  activity 
occurring  paroxysmally,  such  as  hallucinations  and  the  like. 

The  author  enters  his  protest  against  the  use  of  the  term  spinal  epilepsy,  which 
was  originally  introduced  by  Brown- Sequard,  even  in  those  cases  in  which  an 
actually  existing  epilepsy  is  developed  in  consequence  of  an  affection  of  the  spine. 
In  these  cases,  he  says,  it  has  a  certain  justification,  but  is  superfluous,  and  had 
better  be  replaced  by  the  term  secondary  epilepsy.  But  he  characterizes  it  as  a 
misnomer  when  applied  to  the  clonic  and  tonic  seizures  which  occur  as  a  symptom 


506 


Bibliographical  Notices. 


[Oct. 


in  spinal  affections,  -which  remain  confined  to  the  extremities  or  even  to  the  legs, 
and  are  unaccompanied  by  any  trace  of  mental  changes.  With  just  as  much 
propriety,  he  adds,  could  we  speak  of  a  spinal  accessory  or  median  epilepsy  in 
the  case  of  clonic  twitchings  of  the  muscles  of  the  fingers  or  of  the  neck  which 
proceed  from  a  peripheral  affection  of  the  median  or  spinal  accessory  nerve. 

Prof.  Nothnagel  attaches  much  importance  to  hereditary  influence  in  the  pro- 
duction of  epilepsy.  He  does  not  mean  of  course  that  the  term  inherited  tendency 
should  be  taken  in  a  limited  sense,  as  if  strictly  epilepsy  only  in  the  ancestors  led 
to  the  redevelopment  of  the  disease  in  the  descendants.  On  the  contrary,  it  must 
be  taken  in  a  broader  sense,  and  since  it  is  the  neurotic  diathesis  which  is  inherited, 
as  was  long  ago  insisted  upon  by  Trousseau,  the  proposition  may  be  enunciated 
that  any  neurosis  in  the  parents,  whether  it  be  of  a  lighter  or  more  serious  kind, 
may  plant  in  the  children  the  germ  which  may  develop  into  epilepsy.  Where 
the  disease  is  inherited,  its  first  manifestations  generally  occur  early  in  life.  It 
does  not  appear,  however,  that  mental  disturbances  occur  earlier  or  more  fre- 
quently in  this  than  in  other  forms,  the  intelligence  being  more  impaired  by  a 
frequent  recurrence  of  the  attacks  than  by  any  other  cause. 

Compared  with  inherited  tendency  all  the  other  influences  which  affect  the 
organism  or  the  nervous  system  as  a  whole  sink  into  insignificance  as  causes  of 
epilepsy.  It  may,  indeed,  be  asserted  that  most  of  these  are  without  the  power  to 
produce  the  central  change  upon  which  the  disease  depends,  and  that  in  cases 
where  they  have  seemed  to  do  this,  they  have  merely  acted  as  the  exciting  causes 
of  the  first  attack. 

The  author  does  not  regard  the  prognosis  of  epilepsy  as  necessarily  hopeless, 
although  unable  to  verify  by  experience  the  very  favourable  results  of  Herpin, 
according  to  whom  fifty  per  cent,  of  all  epileptics  are  curable.  Unquestionably 
a  certain  number  recover  spontaneously.  Others  get  well  upon  the  removal  of 
the  cause,  and  others  are  restored  to  health  by  means  of  appropriate  treatment. 
The  last  are,  however,  a  very  small  proportion  of  the  whole  number ;  the  pros- 
pect of  recovery  being  of  course  best  in  those  cases  in  which  treatment  is  begun 
soon  after  the  first  appearance  of  the  seizures.  It  is  said  by  Herpin  to  be  good  also 
in  those  cases  which  first  begin  after  the  fiftieth  year. 

When  speaking  of  the  treatment  of  epilepsy,  Prof.  Nothnagel  says  our  success 
will  depend  very  much  upon  the  judgment  with  which  we  select  the  remedies 
appropriate  to  the  case  in  hand  ;  but  it  is  to  be  regretted  that  he  does  not  lay 
down  any  positive  rules  for  our  guidance.  Indeed,  beyond  telling  us  that  iron  is 
to  be  given  to  anaemic  patients,  that  plethora  only  requires  treatment  when  exces- 
sive, and  that  the  oxide  of  zinc  is  most  efficient  with  patients  under  twenty  years 
of  age,  he  gives  us  none  at  all.  It  need  hardly  be  added  that  bromide  of  potas- 
sium is  the  remedy  upon  which  he  places  most  reliance,  saying  of  it,  that,  while  it 
is  not  an  infallible,  sovereign  anti-epileptic,  it  is  certainly  of  more  service  than  all 
other  remedies.  In  some  cases  in  which  it  failed  to  produce  any  good  results,  an 
improvement  followed  its  use  when  given  in  combination  with  oxide  of  zinc.  The 
cold-water  treatment  vigorously  followed  out  has  also  sometimes  in  his  experience 
been  of  great  service. 

In  the  course  of  his  article  on  chorea.  Prof.  Ziemssen  takes  occasion  to  assert 
his  belief  that  "the  group  of  symptoms  called  chorea  major  is  not  a  disease  sui 
generis,  but  is  only  the  product  of  genuine  psyehores  and  cerebral  maladies  on 
the  one  hand,  and  of  hysteria  and  wilful  simulation  on  the  other,"  a  conclusion 
which  is  certainly  true  of  the  great  majority  of  the  cases.  As  regards  the  con- 
nection between  rheumatism  and  chorea  the  author  says  that  their  coexistence  is 
so  frequent  as  to  indicate  that  they  are  the  same  affection  under  two  forms.  In 
common  with  most  other  writers,  he  places  the  seat  of  the  changes  upon  which 


1878.] 


Mauthnek,  Lectures  on  Ophthalmology. 


507 


the  disease  depends  in  the  brain,  and  especially  in  the  great  ganglia  at  its  base, 
and  says  that  these  changes  are  induced,  in  some  cases  at  least,  by  embolic  pro- 
cesses. He  admits,  however,  that  there  are  others  which  cannot  be  explained  in 
this  way. 

The  remedies  upon  which  the  author  relies  principally  in  the  treatment  01 
chorea  are  arsenic  and  hydrate  of  chloral  given  in  decidedly  larger  doses  than 
usually  recommended.  On  the  other  hand,  he  speaks  disparagingly  of  the  bro- 
mides and  electricity,  and  only  doubtfully  of  the  cold-water  treatment. 

A  very  full  description  of  hysteria,  by  Jolly,  follows  the  article  on  chorea,  in 
which  the  reader  will  find  the  various  phases  under  which  this  chameleon  disease 
presents  itself  fully  considered.  And  to  this  succeeds  an  elaborate  essay,  occupy- 
ing nearly  a  third  of  the  volume,  by  Kussmaul,  on  Disturbances  of  Speech— an 
Attempt  in  the  Pathology  of  Speech.  AVe  can  recommend  this  most  cordially  to 
the  student's  attention,  but  unfortunately  it  is  impossible  to  analyze  it  or  even  to 
criticize  it  within  the  limits  allowed  us  for  this  notice.  J.  H.  H. 

\ 


Art.  XXIV.  —  Yortraege  aus  dem  Gcsammtgebiete  der  AugenlieVlcuiule  fur 
Studirende  und  Aerzte.  Von  Dr.  Ludwig  Mauthner,  K.  K.  Universitaets- 
Professor  in  Wien.  Erstes  Heft :  Die  Sympathischen  Augenleiden.  Erste 
Abtheilung:  Aetiologie,  Pathologic.  8vo.  pp.  58.  Wiesbaden:  J.  F.  Berg- 
mann.    New  York:  B.  Westermann  &  Co.,  1878. 

Lectures  on  Ophthalmology  for  Students  and  Physicians.  By  Dr.  Ludwig 
Mauthner,  Imperial-Royal  University  Professor  in  Vienna.  First  Part : 
Sympathetic  Diseases  of  the  Eye.     First  Section :   Etiology,  Pathology. 

These  lectures  or  clinical  studies  by  Professor  Mauthner,  of  which  this  is  the 
first  instalment,  will  embrace  the  entire  field  of  ophthalmology,  and  will  appear 
from  four  to  six  times  a  year,  at  irregular  intervals.  Their  author  is  one  of  the 
most  scientific  of  living  ophthalmologists,  and  his  purpose  of  so  popularizing  the 
study  of  diseases  of  the  eye  as  to  be  of  interest  and  profit  to  all  classes  of  medical 
men,  will  prove  eminently  successful,  if  we  may  judge  from  our  personal  knowl- 
edge of  the  man,  and  from  a  perusal  of  this  first  part  of  his  work. 

The  brochure  of  58  pages  treats  in  the  most  masterly  manner  of  the  etiology 
and  pathology  of  the  sympathetic  diseases  of  the  eye,  and  the  conclusion  of  this 
branch  of  the  subject  will  appear  in  the  second  part  of  the  work,  which  is  shortly 
to  be  published.  Mauthner  begins  with  a  most  excellent  definition,  as  follows : 
"Those  diseases  or  affections  which  are  produced  in  one  eye  by  disease  in  the 
other,  in  which  the  disease  of  the  first  eye  is  the  sole  cause  of  disease  in  the  sec- 
ond eye,  are  termed  sympathetic ;"  and  if  we  stand  rigidly  by  this  definition,  we 
shall  make  but  few  mistakes  in  diagnosis. 

Mauthner  devotes  a  short  preliminary  section  to  the  coarse  or  topographical 
anatomy  of  the  eyeball,  with  special  consideration  of  the  so-called  ciliary  region, 
and  then  proceeds  to  discuss  the  various  lesions  which  may  lead  to  sympathetic 
trouble.  Lesions  of  the  ciliary  region  may  be  spontaneous  in  origin  as  well  as 
traumatic,  though  the  latter  are  the  more  frequent.  The  danger  of  injuries  in 
this  region  is  certainly  very  great,  and  not  unfrequently  the  most  unfortunate 
results  follow  operations  here. 

Mauthner  also  calls  attention  to  the  fact  that  traumatic  lesions  of  this  region 
may  spontaneously  turn  out  well,  and  a  good  result  may  be  reached,  and  gives 
the  history  of  an  interesting  case  of  this  kind.    Even  where  a  foreign  body  has 


508 


Bibliographical  Notices. 


[Oct. 


remained  imbedded  for  years  in  an  eye,  causing  from  time  to  time  violent  inflam- 
mation, but  without  setting  up  any  sympathetic  trouble,  it  may  finally  bring 
about  perforation  of  the  eyeball  and  its  own  elimination  during  a  violent  inflam- 
matory attack. 

Injuries  in  the  ciliary  region  Mauthner  divides  into  accidental  and  operative. 
Under  the  former  head  he  considers  the  imbedding  of  a  foreign  body  in  the 
ciliary  body  ;  injury  of  the  ciliary  body  by  pointed  or  cutting  instruments  without 
remaining  imbedded  here  ;  bruising  and  tearing  of  this  region  by  blunt  objects  : 
incised,  punctate,  and  lacerated  wounds  of  the  corneal  margin,  with  or  without 
injury  of  the  ciliary  body,  with  prolapse  of  iris  or  ciliary  body  in  the  wound ; 
finally  contusions  of  the  eyeball  in  this  region.  Mauthner  recognizes  the  fact 
that  a  foreign  body  may  remain  free  or  encapsuled  in  any  part  of  the  eye  for 
many  years  without  causing  any  trouble,  but  believes  that  sooner  or  later  condi- 
tions will  arise  that  may  threaten  sympathetic  trouble.  He  then  gives  a  simple 
yet  admirable  sketch  of  the  various  severe  symptoms  of  inflammation  following 
an  injury,  from  the  deep  pericorneal  injection  through  all  the  stages  to  phthisis 
bulbi  or  atrophy  of  the  eyeball.  In  this  prolonged  process,  cyelitis  plays  an  im- 
portant part,  and  is  the  last  to  die  out,  for  the  region  of  the  ciliary  body  remains 
sensitive  and  painful,  even  after  pronounced  atrophy  has  appeared. 

In  speaking  of  the  serious  results  which  sometimes  follow  operations,  Mauth- 
ner considers  at  length  the  operation  of  iridectomy  for  optical  purposes,  its  failure 
to  produce  the  desired  effect,  and  the  introduction  of  the  operation  of  iridodesis  in 
its  place.  This  was  first  regarded  as  absolutely  harmless,  but  since  18G3  a  large 
number  of  cases  have  been  published  in  which  bad  results  followed  the  operation, 
and  in  not  a  few  of  these  was  sympathetic  inflammation  of  the  fellow  eye  a  result, 
directly  traceable  to  the  operation. 

He  then  takes  up  the  subject  of  extraction  of  cataract  by  the  flap  method,  as 
well  as  by  the  peripherical  linear  method  of  von  Graefe,  and  proves  that  the  latter 
has  much  more  frequently  been  the  indirect  cause  of  sympathetic  irritation  than 
the  old  flap  method.  The  subject  of  idiopathic  inflammation  of  the  ciliary  body 
and  choroid  is  considered  next,  its  rarity  recognized,  and  yet  its  undoubted  influ- 
ence in  causing  sympathetic  trouble  plainly  affirmed,  and  reference  is  made  to 
the  cases  of  Noyes  and  Jeffries,  in  which  the  sympathetic  irritation  arose  from 
herpes  zoster  ophthalmicus  of  the  opposite  side.  From  all  that  has  gone  before, 
it  is  plain  to  see  that  the  disease  of  the  uveal  tract  under  consideration  is  an  in- 
sidious, more  or  less  chronic,  plastic  inflammatory  process.  But  Mauthner  very 
justly  takes  up  the  following  questions  :  1.  Can  a  violent  purulent  inflammation 
of  the  uveal  tract  lead  to  sympathetic  trouble  ?  2.  Can  this  occur  when  the 
ciliary  body  is  not  involved,  nor  the  ciliary  region  sensitive  to  the  touch,  the  iris 
or  choroid  alone  being  inflamed  ?  3.  Finally,  can  sympathetic  trouble  be  pro- 
duced without  disease  of  the  uveal  tract  ?  The  first  of  these  he  answers  in  the 
affirmative,  and  corroborates  his  own  view  by  cases  reported  by  Mooren  and  Ros- 
sander,  and  by  the  pathological  report  of  Arlt.  The  other  two  questions  receive 
also  a  most  emphatic  affirmative  answer,  especially  from  the  side  of  microscopical 
and  pathological  investigations. 

In  addition  to  these  points,  Mauthner  brings  up  a  still  more  important  question, 
which  has  recently  been  the  subject  of  much  discussion,  viz.  :  If  in  the  case  of 
traumatic  cyelitis,  without  the  presence  of  a  foreign  body,  the  inflammation  has 
not  led  to  atrophy  of  the  eyeball,  but  has  ended  in  complete  recovery,  can,  subse- 
quently, sympathetic  trouble  break  out  in  the  fellow  eye  ?  He  considers  the 
subject  by  citing  a  case  in  detail,  and  concludes  that  even  such  a  favourable  result 
of  an  injury  is  no  sure  protection  against  sympathetic  trouble. 


1878. j  Matjthner,  Lectures  on  Ophthalmology.  509 


In  the  second  part  of  this  brochure  the  author  considers  briefly  the  various 
forms  in  which  sympathetic  trouble  may  present  itself,  carefully  distinguishing 
between  sympathetic  irritation  and  sympathetic  inflammation.  If  at  the  time  of 
the  sympathetic  irritation  there  is  no  actual  disease  present,  we  must  consider  it  a 
case  of  irritation  of  the  ciliary  nerves,  and  Mauthner  is  inclined  to  look  for  the  pri- 
mary affection  in  the  retina,  which  produces  a  reflex  neurosis  of  the  ciliary  nerves, 
and  hence  the  asthenopie  symptoms.  At  the  same  time  he  admits  that  primary 
ciliary  neuralgia  may  precede  sympathetic  trouble,  but  in  such  cases  the  ciliary 
region  is  sensitive  to  pressure.  When  the  sympathetic  trouble  is  situated  in  the 
optic  nerve  and  retina,  there  may  be  the  most  violent  photophobia,  photopsia, 
and  blepharospasm,  with  marked  functional  disturbance,  without  there  being  any 
demonstrable  lesion  present.  Mauthner  then  considers  the  subject  of  sympathetic 
inflammation  with  all  its  protean  manifestations,  which  is  always  preceded  by  the 
signs  of  irritation.  He  gives  an  exceedingly  clear  and  accurate  description  of 
serous  and  plastic  iritis  with  corneal  complication,  and  very  justly  differentiates 
strictly  between  membraniform  obstruction  of  the  pupil  and  absolute  closure  of 
the  pupil  by  broad,  continuous  posterior  synechias.  This  distinction  is  too  often 
neglected  in  ophthalmological  writings.  The  former  obstructs  the  passage  of 
light,  but  does  not  necessarily  injure  the  eye.  The  latter  offers  no  obstruction 
to  the  rays  of  light,  but  is  a  source  of  constant  danger  to  the  eye.  The  conse- 
quences of  this  latter  condition,  and  its  almost  constant  termination  in  destruction 
of  the  eye,  are  admirably  presented.  To  the  plastic  form  of  inflammation,  in- 
volving both  iris  and  ciliary  body,  Mauthner  gives  the  name  "maligna,"  and 
with  justice,  for  it  may  be  said  that  all  treatment  is  useless,  and  unfortunately  it 
occurs  more  frequently  than  the  other  forms  of  sympathetic  inflammation.  He 
states  positively  that  the  "iritis  serosa"  must  not  be  regarded  as  heralding  the 
•plastic"  or  "malignant"  forms  of  inflammation;  that  the  former  has  no  ten- 
dency to  change  into  the  latter,  and  may  even  result  favourably  without  resorting 
to  enucleation  of  the  eye  first  affected.  He  then  makes  the  bold  assertion  that 
when  an  "iritis  serosa,"  after  enucleation,  assumes  the  more  dangerous  plastic 
or  malignant  forms,  it  is  because  the  enucleation  has  excited  a  new  sympathetic 
process. 

The  combination  of  choroiditis  and  retinitis  as  a  form  of  sympathetic  inflamma- 
tion is  fully  recognized  by  the  author,  who  gives  it  a  degree  of  importance  which 
it  has  not  until  very  recently  received.  Sympathetic  retinitis,  he  thinks,  occurs 
oftener  than  has  hitherto  been  believed.  The  question  of  sympathetic  affections 
of  the  optic  nerve  he  regards  as  still  very  obscure,  though  he  thinks  that  simple 
atrophy  of  the  nerve  may  be  of  sympathetic  origin. 

Mauthner  regards  the  occurrence  of  acute  glaucoma  as  a  sign  of  sympathetic 
inflammation  as  very  doubtful,  and  up  to  this  time  not  proven.  By  this  he  means 
primary  glaucoma,  with  the  acute  inflammatory  symptoms  peculiar  to  it.  He 
admits  the  occurrence  of  glaucomatous  symptoms,  especially  increased  intraocular 
tension,  in  the  course  of  an  iridocyclitis,  but  this  is  not  primary  glaucoma. 

The  first  part  is  brought  to  an  end  by  a  re^sumi,  of  its  contents,  and  is  an  ad- 
mirable piece  of  work.  C.  S.  B. 


510 


Bibliographical  Notices. 


[Oct 


Art.  XXV. — Beitrage  zur  Praktischen  Augenheilkunde.  Von  Dr.  J.  Hirsch- 
berg,  Docent  an  der  Universit'at  zu  Berlin.  Hefte  I.,  II.,  III.  Berlin: 
Hermann  Peters,  1876.    Leipzig:  Veit  &  Co.,  1877  and  1878. 

Contributions  to  Practical  Ophthalmology.  By  Dr.  J.  Hirschberg,  Lecturer 
in  the  University  of  Berlin.    Parts  I.,  II.,  and  III. 

In  1874  Dr.  Hirschberg  published  a  small  monograph  entitled  "Clinical  Ob- 
servations," and  in  1876  the  first  part  of  the  present  work,  "  Contributions  to 
Practical  Ophthalmology."  There  are  six  chapters  in  this  first  part,  in  which 
are  considered  certain  diseases  of  the  conjunctiva,  cornea  and  sclera,  uveal  tract, 
optic  nerve  and  retina,  lens,  nerves,  and  muscles,  from  a  clinical  and  therapeu- 
tical standpoint.  The  observations  are  based  on  nearly  10,000  cases  occurring 
during  the  years  1873,  1874,  and  1875.  The  first  section  treats  of  blenorrhoea 
neonatorum  and  diphtheritic  conjunctivitis,  and  Hirschberg  considers  that  in  the 
vast  majority  of  cases  the  cause  is  infection  during  parturition  by  means  of  some 
secretion  in  the  genital  passages  of  the  mother.  He  uses  the  term  "ophthalmia 
neonatorum"  as  descriptive,  and  includes  under  it  simple  conjunctival  catarrh, 
as  well  as  exanthematous  conjunctivitis  from  congenital  syphilis,  and  some  other 
affections.  He  cites  some  cases  of  kerato-malakia,  or  simple  suppuration  of  the 
cornea,  without  any  conjunctival  affection,  occurring  in  young  children  with  gen- 
eral marasmus,  and  points  out  that  this  is  a  process  to  be  carefully  differentiated 
from  corneal  suppuration  occurring  with  blenorrhoea.  His  treatment  of  blenor- 
rhoea agrees  with  that  of  most  authors — iced  compresses  and  cleanliness  for  the 
slight  cases,  cauterizations  with  silver  nitrate  for  the  severer  forms,  varying  in 
strength  from  a  solution  of  1^  per  cent,  to  the  use  of  the  lapis  mitigatus.  The 
cases  of  diphtheritic  conjunctivitis  were  almost  all  slight,  and  most  of  them  re- 
covered completely  by  the  simple  use  of  iced  applications  and  bran  poultices. 
The  section  on  abscess  of  the  cornea  and  keratocele  contains  nothing  new  of  im- 
portance. 

In  speaking  of  cyclitis  deformans  find  its  treatment,  Hirschberg  emphasize- 
very  justly  some  rational  ideas,  which  are  the  outgrowth  of  experience.  He  re- 
gards the  only  proper  treatment  to  be  the  enucleation  of  the  inflamed  eye  as  a 
preventive  of  sympathetic  inflammation,  as  all  intra-ocular  operations  on  eyes 
blinded  by  inflammation  of  their  inner  coats  involve  very  great  danger  of  sympa- 
thetic ophthalmia.  This  the  reviewer  regards  as  sound  doctrine,  for  such  eyes 
must  certainly  be  classified  as  among  the  "noli  me  tangere"  cases  of  ophthalmic 
surgery. 

On  the  subject  of  glaucoma,  Hirschberg  regards  the  relative  frequency  of  the 
hemorrhagic  form  as  very  great  in  his  own  experience.  These  cases  are  of  the 
most  malignant  type. 

Under  the  head  of  diseases  of  the  optic  nerve  and  retina,  Hirschberg  gives  the 
histories  of  two  interesting  cases  of  degeneration  of  the  optic  nerve  from  intra- 
uterine deformity  of  the  skull.  The  skulls  were  very  high  and  narrow,  as  if 
compressed  laterally,  and  the  interpalpebral  slit  resembled  the  Mongolian  con- 
formation. 

The  author  regards  diffuse  syphilitic  retinitis  as  very  amenable  to  treatment,  if 
it  is  carried  on  for  a  length  of  time  in  a  darkened  room,  and  even  in  the  worst 
cases,  a  complete  restoration  of  vision  is  possible.  He  cites  six  cases  with  suc- 
cessful result ;  and  a  study  of  them  shows  several  points  of  interest.  The  sub- 
jective prodromal  signs  may  precede  by  a  long  period  the  clouding  of  the  retina 
and  disturbance  of  vision.  Another  case  showed  that  rapid  improvement  may 
take  place  after  two  years  of  constantly  increasing  amblyopia. 


1878.]  Hirschberg,  Contributions  to  Practical  Ophthalmology.  511 


The  last  section  in  this  first  part  is  a  short,  practical  article  upon  the  subject  of 
squint,  with  a  report  of  five  cases,  and  tables  showing  the  result  of  careful  exami- 
nations before  and  after  the  operation,  of  the  muscular  dynamics  of  each  eye, 
with  a  view  to  the  more  exact  dosing  of  the  operation.  The  absolute  necessity 
of  a  quantitative  analysis  of  the  squint  and  of  the  squint- operation  is  often  not 
sufficiently  appreciated. 

The  second  part  contains  the  seventh  annual  report  of  Hirschberg' s  clinic,  as 
well  as  papers  by  Hirschberg  on  "The  Use  of  the  Lance-headed  Knife  in  the 
Extraction  of  Cataract,"  on  "  The  Measurement  of  Refraction  and  a  new  Opto- 
meter;" a  short  paper  by  Thel  on  "Examination  of  the  Upright  Retinal 
Image;"  articles  on  "Enucleation,"  and  "Weber's  Method  of  Extraction," 
by  Pufahl,  and  "  Clinical  Notes,"  by  Rother. 

Hirschberg  speaks  favourably  of  extraction  with  the  lance-knife,  only  lie  prefers 
a  fiat  blade  instead  of  Weber's  concave  one,  and  the  knife  must  be  a  broad  one. 
The  advantages  he  claims  for  the  method  are  rapid  closure  of  the  wound  and 
consequent  early  restoration  of  the  anterior  chamber. 

Hirschberg' s  optometer  consists  of  a  combination  of  two  convex  lenses  of  short, 
but  different  focal  length,  which  produce  an  inverted  image  of  an  object.  Hence 
in  testing  a  patient's  refraction,  the  test-types  must  be  placed  upside  down.  In 
its  practical  application,  if  it  is  desired  to  produce  a  sharp  image  of  the  types  in 
an  emmetropic  eye,  the  distance  between  the  two  convex  lenses  must  be  equal  to 
the  sum  of  the  focal  lengths  of  the  two  lenses.  If  the  eye  examined  be  myopic, 
the  distance  between  ocular  and  objective  must  be  less  than  the  sum  of  their  focal 
lengths,  and  greater  than  the  focal  length  of  the  first.  If  the  eye  examined  be 
hypermetropic,  the  distance  between  the  ocular  and  objective  must  be  greater 
than  the  sum  of  their  focal  lengths.  These  changes  are  made  by  altering  the 
length  of  the  tube  containing  the  lenses  by  means  of  a  screw.  The  instrument 
may  be  used  for  one  eye,  or  two.  Another  advantage  claimed  for  it  by  Hirsch- 
berg is,  that  it  admits  of  a  convenient  and  sure  control  of  the  results  of  examina- 
tion, when  based  on  a  patient's  statements.  If  the  optometer  is  reversed  so  that 
objective  and  ocular  change  roles,  the  constants  are  changed,  and  have  a  different 
value,  so  that  a  very  different  distance  between  the  lenses  is  necessary  for  a  given 
ametropic  eye.  Hirschberg  also  gives  a  table  containing  all  the  necessary  calcula- 
tions for  making  and  corroborating  the  examinations.  Not  to  be  behind  other  oph- 
thalmologists, the  world  over,  Hirschberg  has  also  constructed  an  ophthalmoscope 
of  his  own,  which  only  differs  from  several  of  the  modern  examples,  in  having 
fewer  glasses,  and  these  twice  the  diameter  of  those  in  ordinary  use ;  modifica- 
tions which  have  no  practical  value. 

Thel's  paper  on  "Examination  of  the  Upright  Retinal  Image"  consists  of  a 
mathematical  determination  of  the  proper  correcting  glass  for  the  upright  image, 
with  the  necessary  tables  and  directions  how  to  use  them ;  and  of  a  discussion  upon 
the  enlargement  of  the  upright  image. 

Pufahl' s  article  on  "Enucleation  of  the  Eye"  is  short,  and  contains  nothing  of 
special  interest. 

This  second  part  concludes  with  the  statistics  of  treatment  and  operations  dur- 
ing the  year,  and  short  clinical  notes  of  some  interesting  cases. 

The  third  part  contains  the  eighth  annual  report,  of  Hirschberg 's  clinic,  a  sta- 
tistical report  of  all  the  cases  treated  at  the  clinic  from  1871  to  1877,  and  several 
interesting  papers  by  Hirschberg. 

In  a  paper  on  ' '  Hemianopsia, ' '  Hirschberg  reviews  the  history  of  the  discussion 
of  the  very  important  subject,  the  course  of  the  optic  nerve  fibres  in  the  chiasm 
of  man,  and  gives  an  exhaustive  epitome  of  the  views  held  by  different  authors 
from  Galen  to  the  present  day.    He  calls  attention  to  the  extreme  importance  of 


512 


BlBLIOGRAPniCAL  NOTICES. 


Oct. 


autopsies  in  cases  of  typical  hemianopsia,  with  a  view  to  the  elucidation  of  the 
much-discussed  question  :  "Is  the  decussation  in  the  optic  chiasm  partial  or  com- 
plete?" He  concludes  by  laying  down  as  necessary  postulates  of  the  theory  of 
semi-decussation,  which  he  upholds :  first,  that  homonymous  hemianopsia  occurs 
most  frequently,  is  sharply  defined,  and  may  be  stationary,  that  is  it  may  not  in- 
volve the  intact  halves  of  the  visual  fields  ;  secondly,  that  crossed  temporal  hemi- 
anopsia is  relatively  rarer,  not  so  sharply  defined,  and  is  progressive ;  thirdly, 
that  nasal  hemianopsia  never  occurs. 

In  a  paper  on  the  "Changes  of  the  Fundus  Oculi  in  General  Anaemia" 
Hirschberg  distinguishes  in  the  fundus  three  varieties  of  pathological  appearances. 

1st.  The  optic  papilla  of  both  eyes  becomes  pale,  the  retinal  vessels  remaining 
unchanged,  and  later  becomes  almost  as  white  as  in  extra-ocular  atrophy,  but 
without  the  sharply-defined  limitation  of  the  disk.  The  vision  is  unchanged  un- 
less disturbed  by  exudation  or  hemorrhages  into  the  retina.  This  change  occurs 
both  in  pernicious  and  curable  anaemia. 

2d.  In  chronic  anaemia,  whether  pernicious  or  secondary,  following  loss  of 
blood,  the  optic  papilla  becomes  cloudy- white,  the  vessels  are  narrowed,  especially 
the  arteries,  and  cannot  be  followed  distinctly  for  any  great  distance  beyond  the 
margin  of  the  disk.  There  exists  a  delicate  optic  neuritis  without  much  disturb- 
ance of  vision.  Hemorrhages  and  exudation  may  occur  as  well  here  as  in  the 
first  variety. 

3d.  A  few  days  after  the  loss  of  blood  there  may  occur  a  pronounced  neuro- 
retinitis,  without  any  premonition,  with  great  exudation  and  numerous  hemor- 
rhages, and  disturbance  of  vision,  which  may  lead  in  a  few  days  to  absolute 
amaurosis. 

He  gives  the  histories  of  a  number  of  cases,  which  illustrate  the  three  forms  of 
change. 

The  third  paper,  by  Hirschberg,  is  on  the  "  Elementary  Description  of  Gauss's 
Dioptrics  of  Spherical  Surfaces,"  and  is  purely  mathematical. 

The  last  paper  is  by  Pufahl,  and  consists  of  rather  voluminous  clinical  notes  of 
interesting  cases,  among  which  we  may  note  a  case  of  granuloma  iridis,  one  ot 
choroidal  tubercle,  several  of  congenital  changes  in  the  optic  nerve,  one  of  intra- 
ocular cysticercus,  and  two  of  diabetic  cataract. 

These  brief  publications  contain  many  points  of  interest  to  ophthalmologists, 
and  are  to  be  continued  periodically.  C.  S.  B. 


Art.  XXVI. — Ninth  Annual  Report  of  tlie  State  Board  of  Health  of 
Ifassachusetts.    8vo.  pp.  xl.,  529.    Boston,  1878. 

This  Report  comes  loaded  as  usual  with  valuable  and  interesting  matter. 
From  the  general  report  which  occupies  the  earlier  pages,  as  well  as  from  pas- 
sages in  several  articles  treating  of  the  sanitary  condition  of  special  localities,  we 
learn  that  saturation  of  the  soil  with  various  forms  of  filth  has  become  a  most  im- 
portant and  active  source  of  injury  and  danger  to  the  public  health  in  many  of 
the  towns.  The  State  is  one  of  the  most  densely  populated,  and  oldest  in  the 
Union.  The  natural  tendency  has  been  for  a  progressively  increasing  contami- 
nation of  its  soil,  and  consequently  of  its  air,  and  its  waters  from  wells  or  rivers. 
In  some  districts  where  the  underlying  rock  is  but  thinly  covered  with  soil,  and 
sometimes  so  disposed  as  to  retain  sewage,  or  to  conduct  it  into  wells  or  other 
sources  of  water-supply,  this  cumulative  pollution  is  pretty  clearly  shown  to  exert 
a  decided  and  baneful  effect  upon  the  public  health.    Contamination  of  the  rivers, 


1878.]       Report  of  State  Board  of  Health  of  Massachusetts.  513 


too,  tends  to  become  worse  and  worse.  Unfortunately,  too,  the  protection  of  the 
soil  from  growing  impurity  seems  practically  attainable,  in  many  cases,  only 
through  still  further  use  of  the  streams  as  carriers  of  sewage.  The  dilemma  is  a 
grave  one.  and  not  wholly  susceptible  of  a  satisfactory  disposition.  Of  one  fact, 
however,  the  Board  entertain  no  doubt,  viz.,  that  the  present  danger  from  pollu- 
tion of  rivers  is  much  less  in  Massachusetts,  to-day,  than  that  from  soil-satura- 
tion, with  its  associated  poisoning  of  air  and  of  well-water.  Thus  it  comes  about 
that  the  pollution  of  streams,  great  evil  though  it  be,  is  rather  to  be  regulated  and 
controlled,  than  attempted  to  be  utterly  prevented. 

The  ascertaining  of  the  impurity  of  well-waters  in  different  parts  of  the  State, 
forms  an  important  part  of  the  last  year's  work  of  the  Board.  The  results  of  the 
investigation  are  rather  startling.  They  are,  however,  very  temperately  inter- 
preted— it  being  freely  admitted  that  foul  water  is,  practically,  oftener  a  favouring 
condition,  than  an  actual  cause,  of  disease.  Among  the  points  most  clearly 
brought  out  in  these  researches  we  may  note  these:  that  very  bad  water  is  often 
clear  and  tasteless  ;  that  public  water-supply,  without  a  system  of  sewers,  is  some- 
times productive  of  more  harm  than  good;  and  that  the  connection  of  houses  with 
the  sewers,  unless  very  judiciously  planned  and  performed,  may  also  prove  more 
a  cause  of  disease  than  a  preventive. 

Dr.  Adams,  of  Pittsfield,  gives  a  brief  and  suggestive  account  of  an  experiment 
there  made,  in  the  way  of  "cottage  hospitals,"  for  general  medical  and  surgical 
cases.  There  certainly  are  strong  arguments  in  favour  of  small  hospitals,  scattered 
through  the  country,  homelike,  and  near  to  the  homes  of  the  patients.  We  can 
easily  conceive,  too,  that  some  grave  objections  towards  small  receptacles  for  the 
insane  do  not  hold  as  regards  institutions  such  as  we  have  described.  The  experi- 
mental test,  at  least,  is  not  very  difficult,  nor  very  expensive,  and  affords  to  the 
beneficent  an  opportunity  to  do  good  near  home,  and  to  guide  the  workings  of 
their  own  charities.  Certain  social  peculiarities  of  our  people,  which  in  practice 
render  resort  to  the  great  city  hospitals  very  rare  on  the  part  of  the  rural  popula- 
tion, would  seem  to  point  to  an  even  greater  usefulness  for  such  local  charities, 
here,  than  in  England,  where  the  plan  has  been  somewhat  extensively  followed. 

Prof.  Nichols,  the  distinguished  chemist  of  the  Technology  school,  treats  at 
considerable  length  of  "Filtration  of  Potable  AVater."  A  clear  statement  is 
made  as  to  the  character  of  the  impurities  capable  of  removal.  Attention  is  drawn 
to  a  somewhat  prevalent  muddiness  of  men's  ideas  as  to  the  solution,  or  the  sus- 
pension, of  foreign  matters  in  water.  The  nature  and  scope  of  natural  filtration, 
by  which  the  water  is  collected  only  after  passing  through  filtering  strata  of 
Nature's  arrangement,  is  explained  as  a  preliminary  to  a  somewhat  full  description 
of  the  various  combinations  of  materials  by  which  men  have  copied  the  natural 
process,  both  on  a  large  scale  and  for  the  single  household. 

As  the  results  of  foreign  and  domestic  experience,  and  of  experimental  investi- 
gation by  the  writer,  the  following  conclusions,  with  others,  are  arrived  at.  Sand 
is  the  only  agent  largely  available  for  filtration,  in  supplying  cities  and  towns. 
Such  filtration,  while  it  may  remove  a  portion  of  matter  in  solution,  and  perhaps 
all  that  which  is  merely  suspended,  cannot  be  regarded  as  rendering  a  polluted 
water  safe.  Any  systematic  attempt  at  purifying  a  water-supply  requires  not 
only  a  considerable  outlay  for  the  construction  of  works,  but  also  an  enlightened 
supervision,  and  a  continued  expenditure,  to  keep  the  filters  in  an  effective  con- 
dition. 

Household  filtration  is  treated  of  with  some  minuteness  of  detail.  Animal 
charcoal  is  regarded  as  the  most  effective  purifying  filter.    The  chief  practical 
troubles  are,  first,  that  a  filter  which  is  efficient  delivers  the  water  very  slowly, 
and  second,  that  there  is  constantly  going  on  a  process  of  clogging  and  fouling 
No.  CLII  Oct.  1878.  33 


514  Bibliographical  Notices.  [Oct. 

which  requires  incessant  care,  either  to  maintain  the  purity,  or  the  transmission, 
or  both. 

Various  combinations  and  methods  of  artificial  filtration,  on  large  and  small 
scales,  and  adaptations  of  natural  filtration  to  the  purposes  of  water-supplv.  are 
described  in  detail,  illustrated  by  wood-cuts,  and  tabular  statements  given  of  the 
kind  and  amount  of  purification  attained  in  different  cases. 

An  excellent  feature  of  this  paper,  as  of  some  of  its  companions,  is  a  directory 
to  the  literature  of  the  subject,  which  must  prove  of  great  assistance  to  any  one 
having  occasion  to  make  thorough  investigations  at  short  notice. 

Dr.  D.  F.  Lincoln,  continuing  a  line  of  investigation  in  which  he  has  previously 
elicited  startling  facts,  treats  of  the  sanitary  conditions  of  public  schools,  including 
their  agency  as  disseminators  of  contagious  diseases.  The  method,  so  much  em- 
ployed by  this  Board,  of  circular  letters  of  inquiry,  has  here  again  been  used  to 
collect  facts  and  opinions  from  all  parts  of  the  State.  The  questions  were  addressed, 
not  to  teachers,  but  to  prominent  physicians  who  had  consented  to  act  as  "  medical 
correspondents"  of  the  Board.  While  confirming  the  views  formerly  expressed, 
by  Dr.  Lincoln  and  by  others,  in  different  parts  of  the  country,  as  to  the  general 
existence  of  unwholesome  conditions,  in  and  around  our  schools,  this  paper  requires 
no  especial  comment  in  addition  to  what  we  have  recently  said  in  other  connec- 
tions. The  evils  which  cluster  about  our  schools,  dependent  on  construction,  loca- 
tion, and  management,  are  certainly  very  real  and  very  grave.  Neither  physicians 
nor  parents  should  ever  cease  to  critically  examine  the  conditions  under  which  so 
many  hours  of  children's  lives  are  daily  passed. 

Dr.  A.  H.  Johnson,  of  Salem,  has  prepared  an  article  upon  scarlet  fever.  It 
is  designed  to  convey  to  all  intelligent  readers  such  knowledge  of  the  nature  and 
conditions  of  the  disease  as  may  enable  them  to  take  all  proper  precautions  against 
its  occurrence  and  its  communication.  A  good  deal  of  space  is  devoted  to  the 
importance  of  disinfection, — of  clothes,  other  portable  articles,  furniture,  and  the 
sick-rooms.  The  methods  by  which  this  can  be  best  accomplished,  and  the  spread 
of  the  malady  prevented,  are  here  treated  in  a  very  practical  and  useful  way. 
This  is  one  of  the  papers  whose  general  circulation,  in  the  form  of  a  cheap  tract, 
might  be  of  great  service.  The  amount  of  imprudence  and  carelessness,  to  give  it 
no  worse  name,  displayed  by  friends  and  the  public,  in  connection  with  infectious 
diseases,  especially  of  children,  would  seem  almost  incredible,  if  not  daily  wit- 
nessed. Surely  a  large  proportion  of  our  people  need  only  such  enlightenment  as 
is  here  presented  to  abandon  customs  and  practices  which  have  hitherto  done  very 
much  to  multiply  cases  of  this  terrible  class  of  maladies. 

Continuing  a  plan  some  years  ago  adopted  of  presenting  somewhat  elaborate 
statements  of  the  sanitary  condition  and  intluences  of  the  larger  towus  and  cities  of 
the  State,  we  find  in  this  Report  an  examination  into  all  the  circumstances  affect- 
ing the  health  of  the  university  town  of  Cambridge.  The  flatness  of  its  territory, 
but  little  elevated  above  tide- water,  the  vicinity  to  marshy  districts,  and  the  cha- 
racter of  the  subsoil,  are  unfavourable  to  general  healthfulness.  Certain  wards 
have  a  high  death-rate,  and  are  a  constant  menace  to  the  more  favoured  localities. 
As  a  whole,  however,  the  mortality  is  not  excessive. 

The  usual  extracts  from  reports  of  correspondents  from  all  over  the  State,  given 
collectively  under  the  title  "Health  of  Towns,"  are  here  presented.  The  ques- 
tions, to  which  especial  attention  had  been  called,  are  omitted — inadvertently 
we  suppose.  The  average  of  health  as  compared  to  former  years  is  referred  to  by 
nearly  all  reporters.  The  general  testimony  is  to  a  remarkably  high  state  of 
health  for  the  year  1877.  The  very  few  exceptions  are  almost  invariably  caused 
by  some  one  epidemic  disease,  usually  diphtheria.  Boston  shows  a  death-rate  of 
20.72  in  1000,  against  23.84  in  1876.    The  temperature  of  the  year  was  higher. 


1878.]       Report  of  State  Board  of  Health  of  Massachusetts.  515 


but  the  variations  were  les«.  The  very  warm  December,  so  generally  deemed 
"  unhealthy"  by  the  public,  shows  a  very  low  mortality.  The  chief  gain  was  in 
the  fall  and  winter. 

Diphtheria,  while  occasionally  sparing  a  town,  or  appearing  in  a  much  milder 
form  than  in  some  former  year,  furnishes  a  very  large  proportion  of  the  sickness 
and  death  throughout  the  State.  We  cannot  perceive  any  uniformity  in  the 
reports  as  to  its  greater  or  less  severity  of  type  during  the  year.  In  one  town  the 
Cases  may  have  been  generally  mild,  and  in  the  next  perhaps  unusually  severe. 
And  where  it  was  very  fatal  one  year,  it  was  very  slightly  so  another.  In  Bos- 
ton, while  only  about  two-thirds  as  fatal  as  in  1876,  it  furnished  nearly  five  per 
cent,  of  the  total  mortality. 

While  there  is  a  very  large  amount  of  testimony  towards  the  general  existence 
of  filth  or  bad  drainage,  as  an  element  in  the  causation  of  this  disease,  there  is  also 
much  positive  evidence  that  the  disease  sometimes  appears  amid  the  most  favour- 
able surroundings.  In  the  terrible  epidemic  prevalence  of  diphtheria  in  Glouces- 
ter, it  was  moreover  observed  that  some  of  the  worst  localities  were  almost  exempt. 

Many  very  curious  instances  are  given  of  the  methods  by  which  infection  has 
been  carried — but  for  these  we  lack  space.  It  is  evident  however  that  the  profes- 
sion throughout  the  State  are  startled  and  alarmed  at  the  amount  and  fatality  of 
diphtheria  of  late  years.  In  Taunton  there  were  93  deaths  from  diphtheria,  out 
of  a  total  mortality  of  433.  In  Lawrence  out  of  875  deaths  117  were  due  to  this 
cause,  or  13  per  cent.  Lynn  shows  about  the  same  figures,  absolute  and  relative. 
In  Gloucester  also,  the  deaths  from  this  cause  have  been  about  15  per  cent,  of  all, 
while  in  1876  alone,  the  rate  seems  to  have  been  nearly  double  that.  Anions 
smaller  towns,  we  meet  one  with  a  mortality  of  86,  of  which  24  are  attributed  to 
this  disease.  In  another,  about  the  same  number  from  diphtheria,  out  of  a  total 
mortality  of  175.  In  others,  we  find  12  out  of  62  ;  10  or  12  out  of  100;  5  out 
of  42,  14  out  of  94,  10  out  of  70,  6  out  of  42,  etc.  These  figures,  which  are  mere 
examples,  will  well  account  for  the  attention  paid  in  this  report  to  diphtheria. 

Other  zymotic  diseases  do  not  present  any  especial  claims  to  notice.  Typhoid 
fever,  however,  is  several  times  noted  as  less  frequent,  generally  in  connection  with 
mention  of  improved  water-supply.  In  one  town  it  is  said  to  be  nearly  confined 
to  people  who  persist  in  using  well-water.  Particular  cases,  especially  where 
several  occur  in  one  house,  are  generally  attributed  to  bad  water. 

Phthisis  is  in  several  instances  noted  as  furnishing  less  proportionate  mortality 
than  formerly  ;  and  this,  in  one  or  two  larger  cities,  is  attributed  to  the  diminished 
number  of  Irish  emigrants  since  the  "  hard  times."  This  class  have  been  known 
for  some  years  to  contribute  more  than  their  numerical  proportion  to  the  deaths 
from  consumption. 

Two  deaths  from  bites  of  rabid  animals  are  noted  ;  the  first  from  a  dog  not  fully 

reported ;  the  second  from  a  cat,  was  possibly  pseudo-hydrophobia. 

In  connection  with  an  alleged  increase  of  consumption  in  a  manufacturing  town, 
occurring  principally  among  young  Irish  mill-hands,  it  is  stated  that  "  snuff-dip- 
ping" is  a  vice  almost  universal  among  the  female  workers. 

A  special  report  deals  with  diphtheria  as  it  appeared  in  Gloucester  for  a  few 
years  past.  We  will  return  to  this  subject  only  briefly  to  note  the  peculiar  local 
conditions.  The  soil  is  very  thin,  superimposed  upon  solid  granite,  or  occasionally 
upon  clay.  After  rising  somewhat  abruptly  from  the  seaside,  the  surface  is  undu- 
latory,  causing  marshy  spots  and  damp  cellars.  For  two  centuries,  all  excrement 
has  been  placed  in  rudely  built  privies.  Wells,  necessarily  shallow,  owing  to  the 
underlying  rock,  have  provided  drinking  water.  Believing  that  there  must  exist 
contamination  of  this  water,  the  Board  sent  specimens  from  thirty  or  forty  wells 
to  Prof.  Nichols  for  examination.     "Do  people  actually  drink  this  water?"  was 


516 


Bibliographical  Notices. 


[Oct. 


asked  by  the  astonished  workers  in  the  laboratory.  One  sample  is  stated  to  be 
worth  for  manure  "twice  as  much  as  ordinary  sewage,"  but  this  well  had  for 
some  time  been  abandoned.  Two  specimens — equal  as  fertilizers  to  the  contents 
of  the  Pittsfield  sewers,  the  first  from  a  well  in  use  by  three  families  who  are 
"always  well,"  and  the  second  from  a  well  constantly  used  from  birth  by  a  family 
of  exceptionally  robust  children — are  mentioned  as  proof  that  foul  water  alone 
will  not  cause  diphtheria  or  other  disease.  Yet  not  only  these,  but  all  the  waters 
tested,  were  pronounced  unfit  for  human  consumption.  In  spite  of  the  extraordi- 
nary exceptions  above  noted,  we  presume  our  readers  will  agree  with  the  Board 
in  believing  that  there  is  some  connection  between  the  diphtheria  and  the  water, 
in  the  sea-girt  peninsula  inhabited  by  hardy  fishermen  and  their  industrious  and 
intelligent  families. 

One  or  two  other  special  reports,  and  a  tolerable  index,  complete  this  excel- 
lent Report.  Many  matters  of  great  interest  we  have  been  obliged  to  touch 
hurriedly  or  to  ignore  entirely.  The  work  is  an  acquisition  to  any  medical  library 
fortunate  enough  to  get  it.  B.  L.  K. 


Art.  XXVII. — Transactions  of  State  Medical  Societies. 

1.  Transactions  of  the  Medical  Association  of  Georgia,  April,  1878,  pp.  279. 

Atlanta,  Ga.,  1878. 

2.  Transactions  of  the  Mississipjn  State  Medical  Association,  April,  1878, 

pp  1G8.    Jackson,  Miss.,  1878. 

3.  Transactions  of  the  Iowa  State  Medical  Society,  May,  1877,  and  Jan. 

1878,  pp.  196.    Des  Moines,  1878. 

4.  Transactions  of  the  Vermont  Medical  Society,  June,  1877,  pp.  88.  St. 

Albans,  Vt.,  1878. 

5.  Transactions  of  the  Rhode  Island  Medical  Society  for  1877  and  1878,  pp. 

49.    Central  Falls,  1878. 

6.  Proceedings  of  the  Connecticut  Medical  Society,  May,  1871,  pp.  234. 

Hartford,  Conn.,  1878. 

1.  We  regret  to  learn,  from  the  Georgia  Transactions,  that  the  recently  organ- 
ized Health  Board  of  that  State  has  been  rendered,  of  late,  practically  inoperative, 
through  the  short-sighted  parsimony  of  the  Legislature.  The  liability  to  occa- 
sional invasions  of  yellow  fever,  should  alone  amply  justify,  to  the  dullest  law- 
giver, the  expenditure  necessary  to  maintain  the  Board. 

Dr.  Walker  reports  the  delivery  of  a  dead  foetus,  apparently  of  two  and  a  half 
months,  coincidently  with  a  fully  developed  and  living  infant.  A  discharge  of 
fluid,  supposed  to  be  amniotic,  had  occurred  one  week  before  the  final  labour. 
The  doctor  believes  that  the  younger  embryo  ceased  to  live  at  this  time,  and  that 
it  was,  as  it  appeared,  the  fruit  of  conception  occurring  during  advanced  preg- 
nancy. It  was  delivered  after  the  living  child,  and  before  the  developed  pla- 
centa. A  cord  some  six  inches  in  length  was  attached  to  it,  but  no  separate  pla- 
centa, nor  any  connection  with  the  other  cord  or  membranes  could  be  detected. 

Professedly  limiting  himself  to  the  disease  as  observed  in  the  epidemic  of  1876, 
Dr.  Le  Hardy  examines  with  some  minuteness  the  history  of  yellow  fever,  as  pre- 
vailing in  Savannah,  from  its  earliest  appearance.  He  believes  the  disease  can 
and  does  originate  on  the  spot,  independently  of  any  importation.  High  tem- 
perature with  great  humidity  of  air,  in  connection  with  stagnant  waters  upon  the 
rice-swamps,  furnish  the  conditions  under  which  the  disease  is  born.  Quarantine 
or  the  imposing  of  long  seclusion  and  delay  upon  persons  and  cargoes  from  in- 


1878.] 


Transactions  of  State  Medical  Societies. 


517 


fected  ports,  he  believes  to  be  useless.  All  good  purposes  can  be  effected  in  a 
few  hours,  by  "  modern  scientific  disinfection." 

During  seventy-five  years,  previous  to  the  beginning  of  rice  cultivation,  the 
writer  says  yellow  fever  was  unknown ;  while  malarial  diseases  generally  are 
represented  to  have  been  little  prevalent.  Yet  communication  was  frequent  with 
Charleston  and  the  West  Indies,  where  the  fever  was  respectively  epidemic  and 
endemic.  Early  in  the  present  century,  however,  the  swamps  around  the  city 
began  to  be  extensively  cultivated,  especially  for  the  growth  of  rice ;  and  there 
is  reported  to  have  occurred  a  very  marked  change  for  the  worse  in  the  sanitary 
character  of  the  place.  Then  only  did  the  yellow  fever  begin  to  appear.  It  does 
not  seem  to  have  been  distinctly  separated  by  physicians,  at  first,  but  is  spoken  of 
as  a  malarial  fever  of  a  continued  type,  ending  in  black  vomit.  Another  alleged 
fact  would  seem  to  possess  great  significance,  though  not  here  quite  clearly  set 
forth — experiments  made  on  certain  years  in  what  is  called  the  "  dry  culture"  of 
the  rice,  seem  to  have  uniformly  coincided  with  freedom  from  this  fever,  and 
with  a  general  high  standard  of  health. 

While  not  denying  the  theoretical  possibility  of  imported  cases  being  the  ex- 
citing cause  of  local  cases,  under  suitable  conditions,  the  writer  points  to  the  actual 
rarity  of  such  instances  in  the  oldest  records ;  also  to  the  frequency  with  which 
the  former  cases  have  run  their  course  without  causing  the  latter ;  and  to  the  fact 
that  while  in  the  West  Indies  yellow  fever  prevails  in  March,  April,  and  May,  it 
never  appears  in  Savannah  till  the  end  of  July,  or  generally  later. 

We  are  not  quite  sure  that  we  understand  the  author's  views  as  to  the  nature  of 
the  malady  in  question.  He  expresses  with  much  emphasis  a  belief  in  the  "ma- 
larial" character  of  the  disease.  Often  in  speaking  of  the  fevers  of  certain  years 
he  conveys  the  impression  of  the  yellow  fever  being  merely  a  more  extreme  ex- 
pression of  the  same  poison  which  produced  the  intermittent,  due  to  great  heat 
and  other  intensified  conditions.  And  yet  he  seems  inclined  to  believe  that  he 
has  identified  a  particular  fungous  growth  with  yellow  fever.  Surely  it  is  hardly 
reasonable  thus  at  once  to  imply  identity  and  difference. 

Thorough  drainage  of  the  city  and  the  surrounding  marshes — including,  we 
presume,  abandonment  of  the  "wet  culture"  of  rice — is  designated  as  the  only 
effective  prophylaxis.  Hot  mustard  baths,  with  frictions,  a  ten-grain  dose  of 
calomel,  followed  by  a  laxative,  with  perhaps  a  bland  emetic,  followed  by  an  epi- 
gastric sinapism,  were  found  the  best  treatment  at  the  outset  of  most  cases.  If 
needful,  to  restore  circulation  and  cause  sweating,  the  baths  were  repeated,  taking- 
care  to  have  the  patient  wrapped  in  a  steaming  blanket  while  in  transit  to  his 
bed.  Quinia  in  five-  or  ten-grain  doses  was  then  commenced  and  continued  from 
two  to  four  days,  or  till  the  temperature  became  normal.  When  irritability  of 
the  stomach  was  extreme,  resisting  ice  and  effervescents,  entire  rest  was  given  it, 
a  blister  applied  to  epigastrium,  and  nutrient  enemata  given.  Beef-tea  was  the 
food  preferred,  given  either  from  above  or  below.  When  enemata  only  were 
relied  upon,  an  egg  and  fifteen  or  twenty  grains  of  sulphate  of  quinia  were  given, 
with  a  half  ounce  of  the  tea  every  four  hours. 

Dr.  Calhoun,  in  presenting  the  lessons  of  his  experience  in  130  operations  for 
strabismus,  notes  the  extreme  rareness  of  this  affection  among  the  negroes.  My- 
opia and  presbyopia  are  also  very  rare  in  this  class.  ' 

Besides  an  instructive  report  on  Gynaecology  by  Dr.  A.  W.  Griggs,  we  have  a 
useful  paper  upon  the  use  of  uterine  tents  by  Dr.  W.  T.  Goldsmith,  and  one  on  the 
application  of  pressure  in  uterine  diseases,  by  Dr.  V.  H.  Taliaferro.  The  last-men- 
tioned paper  is  a  peculiarly  practical  and,  we  incline  to  believe,  useful  one.  Hav- 
ing discovered,  as  it  were  by  accident,  that  the  support  and  pressure  exerted  on 
the  vessels  and  tissues  of  a  lax,  enlarged,  and  congested  uterus,  by  a  very  tightly 


518 


Bibliographical  Notices. 


[Oct. 


tamponed  vagina,  caused  a  wonderful  return  towards  a  normal  tonicity  of  the 
flaccid  organ,  Dr.  T.  continued  the  treatment  with  excellent  effect,  and  applied 
his  new  idea  to  other  cases.  He  summarizes  the  action  of  the  tampon  as  follows  : 
diminishing  blood-supply  and  nutrition ;  promoting  absorption,  and  the  destruc- 
tive metamorphosis  of  redundant  tissue  ;  lessening  nervous  action  ;  and  rectifying 
malpositions.  Thus  it  is  eminently  applicable  to  the  conditions  expressed  by  the 
terms,  subinvolution,  hypertrophy,  hyperplasia,  congestion,  chronic  inflammation 
and  its  products,  fibroid  growths,  and  uterine  hyperesthesia.  To  obtain  the  best 
results  the  vagina  must  be  dilated  by  placing  the  patient  in  the  knee-elbow  or 
knee-chest  posture,  and  the  filling  must  be  very  complete  and  uniform.  Carded 
sheep's  wool  in  pledgets  is  recommended  as  the  best  material — having  been  duly 
disinfected.  One  or  two  pledgets  in  immediate  contact  with  the  os  may  be  of 
cotton  batting,  soaked  in  glycerine,  for  the  sake  of  its  osmotic  action  and  its  disin- 
fectant virtues.  The  tampon  requires  renewal  about  once  in  three  days.  The 
treatment  may  continue  weeks,  or  even  months,  with  intermissions  at  the  men- 
strual periods.  If  the  first  applications  are  a  little  less  tightly  packed,  irritation 
of  the  vagina  is  seldom  caused,  while  the  relief  to  vomiting,  pain,  and  other  dis- 
tressing symptoms  is  often  wonderful. 

Contrasting  the  advantages  of  this  treatment  with  that  by  cauteries,  scarifica- 
tions, etc.,  the  writer  claims  great  success.  The  complete  control  indirectly  ex- 
erted over  sexual  intercourse,  is.  moreover,  no  small  gain.  The  ability  of  the 
patient  to  move  about  with  undiminished  and  even  increased  ease,  is  another 
great  advantage.  There  is  no  destruction  of  mucous  membrane,  and  no  contract- 
ing cicatrices,  as  after  the  use  of  acids  and  other  irritants. 

Dr.  Goldsmith,  besides  giving  a  somewhat  full  statement  and  illustration  of  the 
uses  of  tents,  especially  recommends  a  new  material  of  his  own  suggestion — the 
pith  of  the  common  corn-stalk,  in  a  dry  or  ripened  state.  This  he  believes  to 
possess  the  desired  qualities  in  a  higher  degree  than  any  other  substance  used. 

Dr.  Gray  had  recently  an  opportunity  to  examine  the  head  of  a  young  negro, 
who  had  for  six  years  carried  a  pistol-b;dl  in  his  brain.  He  died  from  bleeding 
of  a  wound  which  divided  the  radial  artery.  The  bullet  entered  over  the  right 
eye.  It  could  not  be  felt  by  cautious  probing.  Xo  pain,  unconsciousness,  or 
other  bad  symptom  followed ;  and  the  boy  was  at  work  in  a  few  days  with  the 
wound  healed.  The  ball  was  found  M  imbedded  in  healthy  brain,  surrounded  by 
a  very  small  quantity  of  slightly  yellow  fluid,"  and  "  covered  (but  not  enveloped) 
by  a  small  portion  of  dura  mater."  Exact  location  of  the  missile  is  not  stated. 
The  patient  had  been  under  the  reporter's  observation  during  the  whole  six  years 
and  had  never  shown  any  cerebral  symptoms.  What  adds  to  the  curiosity  of  the 
case  is  the  fact  that  the  youth  rode  three  miles  on  horseback  to  the  doctor's  office, 
within  twelve  hours  after  the  shooting. 

Dr.  Love,  of  Atlanta,  believes  that  very  important  knowledge  of  the  condition 
of  the  circulation,  digestion,  and  secretions  can  be  gained  by  habitual  observation 
of  the  palate,  especially  its  soft  portion.  Particularly  certain,  as  an  early  indica- 
tion of  a  "bilious"  condition,  is  a  yellow  tinge  in  these  parts.  It  is  claimed, 
too.  that  the  eruption  of  measles,  scarlatina,  or  variola,  becomes  visible  here 
twelve  or  twenty-four  hours  earlier  than  elsewhere. 

Dr.  Leitner  warmly  recommends  tarred  strips  of  cloth  in  place  of  common  ad- 
hesive strips,  and  rollers  smeared  with  the  same  substance,  as  a  surgical  dressing. 
Once  applied  it  rarely  needs  to  be  interfered  with.  It  protects  perfectly  from 
flies,  and,  the  writer  claims,  from  erysipelas  and  gangrene. 

Several  other  papers  complete  this  unusually  good  collection.  It  is  a  pleasure 
to  notice,  moreover,  its  neat  and  tasteful  garb,  and  the  almost  entire  absence  of 
typographical  errors. 


1878.] 


Transactions  of  State  Medical  Societies. 


519 


2.  In  the  pamphlet  containing  the  Transactions  of  the  Mississippi  Society, 
we  learn  from  Dr.  Wirt  Johnson  that  salicylic  acid  has  come  into  extensive  and 
successful  use  in  that  State.  As  an  antiseptic  dressing  in  surgery,  he  prizes  it 
very  highly.  Besides  its  virtues  in  rheumatic  cases,  he  regards  it  as  extremely 
useful  in  diphtheria.  Simple  inflammatory  sore-throat  he  has  found  very  amena- 
ble to  the  local  application  of  a  weak  solution. 

Dr.  Whitehead  claims  exceptional  success  with  diphtheria,  from  small,  altera- 
tive doses  of  calomel  combined  with  bicarbonate  of  soda,  together  with  quinia 
and  iron. 

Dr.  Powell  believes  that  constitutional  syphilis  is  a  milder  disease  in  the  Afri- 
can than  it  is  in  the  white  man.  There  is,  he  claims,  much  more  of  a  tendency 
to  a  spontaneous  disappearance  of  the  taint  from  the  system.  The  disease  is 
more  amenable  to  treatment,  and  the  cures  more  complete  and  lasting.  He  even 
states  that  "syphilis  imparted  from  the  white  to  the  negro,  being  modified,  be- 
comes syphiloid,  producing  chancroid,  rarely  followed  by  secondary  and  tertiary 
symptoms."  The  writer  elsewhere  mentions,  however,  the  frequency  of  syphilis 
as  cause  of  abortion,  premature  labour,  and  infantile  disease;  adding  that  "by 
far  the  greater  number"  of  such  infants  die — mostly  before  the  age  of  two 
years.  We  should  much  like  to  learn  what  foundation  there  really  is  for  this  as- 
sumed difference  between  two  races. 

Dr.  Phares  notes  the  frequency  with  which  immediate  relief  to  agonizing  colic 
is  obtained  by  the  "knee-breast"  posture,  or  by  hanging  the  entire  trunk  and 
head  over  the  bedside,  or  even,  in  extreme  cases,  suspending  the  entire  person 
by  the  ankles. 

Dr.  E.  W.  Hughes  describes  a  terrible  epidemic  of  cerebro-spinal  meningitis, 
which  prevailed  among  negroes  employed  upon  the  fortifications  constructed 
around  Grenada,  in  the  fall  and  winter  of  1862  and  1863.  Usually  without  warn- 
ing, the  patients  were  seized  with  chill,  intense  headache,  with  pain  and  stiffness 
at  back  of  neck,  followed  by  irregularly  intermittent  fever,  vertigo,  intolerance 
of  light,  sound,  and  touch.  Delirium  and  coma  were  common,  with  variable 
affection  of  the  pupils,  deafness,  irregular  and  oppressed  breathing  and  many 
other  symptoms  of  profound  poisoning  of  the  nervous  centres.  Pain  in  head  and 
neck,  retraction  of  the  head,  and  stiffness  of  the  muscles  of  the  posterior  cervical 
region,  were  the  pathognomonic  symptoms.  No  cutaneous  eruption  was  observed, 
except  herpes.  [Would  not  the  colour  of  the  skin  mask  the  characteristic 
blotches?]  The  weather  was  wet  and  very  variable  in  temperature.  The  men 
worked  hard,  often  in  mud  and  water  and  exposed  to  rain  and  sleet.  The  quar- 
ters were  poor  and  crowded ;  the  food  poor ;  and  the  spirit  that  of  discontent, 
depression,  and  home-sickness. 

The  malady  being  deemed  one  of  depressed  vitality,  quinia,  opium,  iron  and 
stimulants  were  given  ;  but  all  the  patients  died.  Autopsies  revealed  intense  con- 
gestion of  the  membranes  and  sinuses  of  the  brain.  The  pia  mater  was  opaque, 
thickened,  adherent  to  the  brain,  and  its  vessels  gorged.  Exudation,  from  tur- 
bid serum  to  viscid  pus,  was  found  between  it  and  the  arachnoid,  especially  at  the 
base.  The  meninges  of  the  cord  were  similarly  affected.  Antiphlogistic  treat- 
ment was  then  tried — venesection,  cups,  and  cold  applications,  with  full  doses  of 
calomel  and  Dover's  powder.  From  this  change  of  treatment,  it  is  claimed  that 
about  one-half  the  cases  were  saved.  Success  depended  on  the  promptness  of  the 
first  measures  ;  no  hope  was  felt  unless  the  cases  were  seen  early.  The  mortality 
of  the  epidemic  was  estimated  at  about  one  hundred — all  young,  stout  men. 

Among  a  number  of  surgical  cases  collected  by  Dr.  Hall  we  find  two  of  bullet- 
wounds  in  head,  with  escape  of  brain-substance,  very  little  shock,  and  scarce  any 
serious  symptoms.  Both  were  youthful  soldiers  in  the  Confederate  army,  and  both 


520 


Bibliographical  Notices. 


[Oct. 


were  living  in  good  health  at  time  of  this  report.  In  one  case  it  is  explicitly 
stated  that  the  ball  remains  in  the  brain,  while  in  the  other  the  same  is  inferred, 
though  not  distinctly  asserted. 

A  singular  case  is  narrated  by  Dr.  Hart,  where  the  stomach  was  partially  ex- 
truded through  a  knife-wound  between  the  eighth  and  ninth  ribs.  The  organ 
being  somewhat  distended,  all  attempts  to  return  it  through  the  cut  failed,  even 
after  enlarging  the  latter,  until  at  last  the  stomach  itself  was  opened,  emptied, 
and  closed  up  again  by  interrupted  suture,  when  it  was  returned  to  its  proper 
location.  Fourteen  days  later,  the  patient,  a  field-hand,  resumed  his  work,  and 
' '  lived  happy  ever  after. ' ' 

3.  The  current  publication  of  the  Iowa  Society  is  chiefly  noteworthy  for  some 
very  sensible  advice  and  suggestion  in  the  President's  address,  by  Dr.  Bulis.  Of 
the  two  days  occupied  by  each  session  of  the  Society,  one  is  taken  up  with 
routine  business.  To  fill  up  the  remaining  time  there  are  often  offered  as  many 
as  fifty  papers.  Of  course,  but  few  of  these  can  be  read  ;  but  in  the  attempt  to 
present  as  many  as  possible  these  few  are  hurried  over  with  no  time  for  question, 
debate,  and  comparison  of  views.  Fewer  contributions,  more  deliberately  con- 
sidered, would  be  more  profitable  to  the  listeners  and  more  encouraging  to  the 
authors. 

The  present  publication,  while  containing  many  articles  which  were  doubtless 
of  use  in  refreshing  the  memories  and  attracting  the  attention  of  those  who  lis- 
tened to  them,  has  little  that  calls  for  our  special  notice. 

We  observe  in  a  notice  of  an  epidemic  of  cerebro-spinal  meningitis,  by  Dr. 
William  Watson,  that  the  frequent  presence  of  herpes  labialis,  and  the  general 
absence  of  any  more  characteristic  eruption,  are  adverted  too — agreeing  some- 
what with  the  cases  described  in  the  Mississippi  transactions.  Here,  as  in  the 
other  epidemic,  the  onset  of  the  disease  was  most  startling  in  its  sudden  severity. 
The  verdict  as  to  treatment  is  different ;  tonics,  anodynes,  stimulants,  and  coun- 
ter-irritation were  found  more  useful  than  depressants. 

4.  We  find  in  the  Vermont  Transactions  a  plain,  unstudied  but  most  graphic  pic- 
ture of  diphtheria,  as  observed  by  Dr.  Calderwood,  in  a  rural  district  in  Northern 
Vermont.  That  such  a  practice  should  have  included  fifty-five  cases  of  this  disease 
in  nine  months,  is  one  of  many  indications  of  the  recent  alarming  prevalence  of 
this  malady  in  New  England.  [See  notice  of  Report  of  Massachusetts  Board 
of  Health.^  Cold,  wet  lands  have  seemed  to  afford  the  most  favourable  condi- 
tions for  its  existence.  A  preceding  summer's  drought,  with  ensuing  low  water 
in  the  wells  and  springs,  have  been  noticed  in  connection  with  epidemic  preva- 
lence. In  one  family  two  fatal  cases  originated  during  extreme  lowness  of  the 
water  in  the  well,  and  while  the  water  looked  milky,  and  was  refused  by  the  cow, 
that  would  suffer  thirst  for  days  before  she  would  drink  it.  The  cases  began  two 
days  apart,  and  both  died  the  same  day.  Two  cousins,  who  came  to  visit  the  sick 
ones,  were  stricken  down  ten  days  after,  and  died  within  a  week.  All  but  two 
of  the  cases  (i.  e.,  53)  occurred  in  a  space  of  four  miles  along  a  river,  and  within 
one  and  a  half  miles  of  its  banks.  Eleven  deaths  took  place.  The  country  was 
hilly,  but  cold  and  wet  from  the  nature  of  the  soil.  Out  of  fifty  cases  tested, 
albuminous  urine  was  found  in  forty-five.  No  special  treatment  is  commended. 
Quinia  and  iron,  with  carbolic  acid  solutions  or  tincture  of  iron  locally,  were 
principally  trusted. 

Dr.  Bullard,  of  St.  Johnsbury,  describes  a  form  of  continued  fever,  prevalent 
in  his  neighbourhood,  which  certainly  seems  different  from  the  typhoid.    It  begins 


1878.] 


Transactions  of  State  Medical  Societies. 


521 


much  like  the  latter,  but  runs  a  longer  course,  has  no  tympanites  nor  abdominal 
tenderness.  Constant  vomiting,  with  progressive  emaciation  and  exhaustion  are 
the  prominent  symptoms.  A  typical  case,  here  described,  died  after  sixty  days 
illness.  A  little  softening  and  congestion  of  the  mucous  membrane  in  the 
stomach  and  duodenum,  were  about  the  only  traces  of  disease  disclosed  by  the 
autopsy,  excepting  frightful  emaciation.  This  form  of  fever  had  never  prevailed 
thereabouts  till  within  three  years  past.  Recovery,  beginning  in  four  to  six 
weeks,  is  very  slow,  with  long-continued  trouble  in  taking  food,  and  persistent 
pains  in  the  muscles,  especially  of  the  limbs.  The  debilitated  and  overworked 
adults,  especially  exhausted  women,  are  the  subjects  ;  very  rarely  children.  The 
cases  known  to  the  reporter  number  17  men  and  64  women  ;  deaths,  5  and  24 
respectively.  There  is  never  discovered  any  affection  of  the  intestinal  glands 
or  indeed  any  other  very  marked  inflammatory  lesion  The  only  symptom  noted 
as  pathognomonic  is  a  peculiar  breath — likened  by  some  to  the  odour  of  garlic, 
and  by  others  to  that  of  valerianic  acid.  This  is  always  present.  The  name 
generally  given  the  malady  is  gastric  fever. 

Dr.  S.  S.  Clark,  in  an  "open  letter,"  administers  to  a  well-known  "Washing- 
ton clergyman  a  scathing  and  merited  rebuke,  for  puffing  a  quack  remedy,  in  a 
"religious"  weekly  of  large  circulation.  Truly,  the  astonishing  gullibility  of 
the  reverend  clergy,  and  the  often  equally  amazing  assumption  to  give  confident 
judgment  on  matters  wholly  without  their  sphere,  is  equally  strange  and  deplora- 
ble. The  simple  testimonials  of  illiterate  and  guileless  shepherds  dwelling  in 
remote  rural  districts,  successively  given  to  almost  every  advertising  quack  of  the 
century,  are  bad  enough,  but  such  recklessness — to  give  it  no  harder  name — as  is 
here  rebuked,  in  a  man  presumptively  not  wholly  destitute  of  knowledge  of  the 
world,  as  well  as  of  books,  is  simply  unpardonable,  save  on  confession  and  re- 
pentance. 

5.  In  the  minutes  of  the  Rhode  Island  Society,  we  find  that  Dr.  W.  W. 
Potter  reported  a  case  of  undoubted  hydrophobia,  which  was  attributed  to  a  bite 
received  three  years  previously.  Death  occurred  after  three  days'  illness.  The 
evidence  is  not  here  stated. 

Of  eleven  cases  of  placenta  prsevia,  seen  by  Dr.  C apron,  eight  only  were  in  his 
own  eight  thousand  deliveries.  Version  and  delivery  at  the  earliest  possible  mo- 
ment, is  his  rule  of  conduct.  Tampons  and  cold  applications  are  used  only  until 
the  os  is  enough  dilated  to  warrant  immediate  action.  One  of  his  eight  cases 
died  from  the  results  of  the  misplaced  organ,  and  another  from  some  other  cause. 
Of  the  consultation  cases,  two  died. 

As  all  over  New  England  diphtheria  attracts  much  attention  from  the  profes- 
sion in  Rhode  Island.  Two  papers  here  treat  of  it,  and  its  sequels.  Dr.  James 
H.  Eldredge,  one  of  the  best  known  and  most  respected  physicians  in  the  State, 
notes  81  deaths  in  two  rural  townships  from  1861  to  1876.  Of  these,  66  were 
children  less  than  six  years  old.  The  disease  could  at  no  time  be  called  epidemic. 
The  cases  appeared  in  detached  groups,  by  families  or  neighbourhoods.  In  1877, 
however,  there  were  reported  no  less  than  47  fatal  cases,  in  the  same  limits. 
This  mortality  exceeded  that  of  any  other  one  disease.  Thirty-five  were  under 
six  years  of  age.  Dr.  Eldredge  agrees  with  Dr.  Caklerwood,  of  Vermont,  as  to 
the  general  principles  of  treatment,  the  usual  percentage  of  deaths  to  cases,  and 
as  to  the  original  systemic  character  of  the  affection.  In  periods  of  epidemic 
prevalence,  the  later  cases  are  less  fatal  than  the  early  ones.  Dr.  Eldredge  is 
confident  that  before  diphtheria  was  generally  recognized  in  this  country,  cases 
were  frequently  diagnosticated  as  scarlet  fever  without  eruption. 


522 


Bibliographical  Nonets. 


[Oct. 


6.  We  are  pleased  to  learn,  from  the  Connecticut  Transactions,  that  the 
legislature  of  that  State  has  granted  the  petition  of  the  Medical  Society  by  estab- 
lishing a  Board  of  Health.  Three  of  its  six  members  are  to  be  physicians.  All 
are  appointed  by  the  Governor. 

From  the  responses  made  to  certain  questions  sent  to  physicians  throughout  the 
State,  we  find  there  is  a  prevailing  belief  in  the  recent  and  continuing  increased 
frequency  of  malarial  diseases,  with  diminution  of  typical  typhoid  fever.  Several 
reporters  believe  that  a  hybrid  fever,  for  which  they  accept  the  name  of  tvpho- 
malarial.  is  progressively  supplanting  or  replacing  the  old-fashioned  typhoid.  As 
in  New  England  generally,  too,  diphtheria  has  of  late  been  occupying  a  very  high 
position  as  a  cause  of  death. 

Some  interesting  cases  are  reported  by  Dr.  Storrs  in  support  of  the  position 
that  typhoid  fever  may  arise  spontaneously.  The  local  causes  here  believed  to 
have  been  efficient,  were  decaying  vegetables  in  the  cellar,  gases  from  a  kitchen 
drain,  a  well  polluted  by  kitchen  slops,  and  emanations  from  a  sewer  draining  off 
both  slops  and  excrement,  which  had  become  obstructed  and  hence  discharged 
bad  air  into  the  house. 

As  to  the  possibility  of  a  spontaneous  origin  for  diphtheria  and  scarlet  fever, 
the  difficulties  of  the  subject  naturally  prevent  many  very  confident  replies.  Some 
gentlemen,  however,  feel  certain  that  they  have  observed  cases  where  communica- 
tion of  infection  from  without  was  impossible. 

Dr.  Coates  reports  a  case  of  extra-uterine  pregnancy,  in  which  gastrotomy  was 
successfully  performed  for  the  removal  of  the  remains  of  the  child,  a  year  after 
the  imperfect  labour.  He  thinks  the  occurrence  of  misplaced  foetal  development 
is  much  more  common  than  is  generally  known — cases  often  failing  to  be  recog- 
nized.  He  has  bees  informed  that  the  encysted  remains  of  such  accidents  have 
been  found  in  a  fat  ewe  and  in  a  sow.  upon  the  slaughtering  of  these  for  food. 
No  history  of  symptoms  was  learned  in  these  cases. 

Dr.  Jewett  reports  a  case  of ''concussion  of  the  brain  and  spinal  cord"  following 
a  railroad  accident.  Excessive  stammering  was  a  prominent  symptom.  Weak- 
ness of  the  lower  extremities  and  areneral  debility  persisted  at  date  of  report,  two 
or  three  years  after  the  accident.  Gradual  improvement,  however,  still  continued. 
He  had  not  formerly  stammered.  As  he  got  better  this  difficulty  disappeared, 
except  when  excited. 

Pure  carbolic  acid  applied  to  boils  and  felons  works  like  a  charm  in  causing 
resolution,  according  to  Dr.  B.  F.  Harrison.  Success  attended  it  even  in  cases 
where  suppuration  had  apparently  begun,  in  felons  that  had  kept  patients  awake 
for  nights. 

Dr.  Wainwright  reports  cure  of  popliteal  aneurism  by  two  hours'  compression 
of  the  femoral  artery,  by  means  of  a  "horse-shoe  tourniquet,"  under  chloroform. 
Kb  ill  effects  followed. 

A  remarkable  instance  of  the  transportation  of  clots  through  the  great  blood- 
vessels is  reported  by  Dr.  I.  W.  Lyon.  A  consumptive  patient  had  an  attack  of 
thrombosis  in  the  left  popliteal  and  femoral  veins.  A  few  days  later  the  corded 
swelling  and  tenderness  had  nearly  disappeared.  Paroxysms  of  dyspnoea  soon 
appeared,  in  one  of  which  he  died.  In  addition  to  the  usual  signs  of  chronic 
phthisis,  perforation  of  the  pleura  was  discovered.  The  venae  cava?  and  right 
heart  were  moderately  fiTed  with  dark  clotted  blood;  in  addition,  the  auricle 
contained  a  thick,  fleshy  coagulum,  nearly  white,  about  two  inches  long,  and  the 
inferior  cava  a  long  and  slender  clot  of  similar  colour  and  consistence.  The  pul- 
monary artery  contained  a  mass  resembling  a  cluster  of"  angle- worms"  ;  a  slender, 
white,  fibrinous  clot  coiled  on  itself,  mixed  with  dark,  jelly-like  coagula,  filling 
the  calibre  of  the  vessel  and  lying  close  up  to  its  bifurcation,  about  an  inch  or 


1878.] 


Beport  on  Pleating  and  Ventilation. 


523 


inch  and  a  half  from  the  valves.  The  unavoidable  inference,  after  a  careful 
examination  by  a  skilful  pathologist,  was  that  this  branching  coagulum  had  been 
formed  in  the  veins  of  the  lower  extremity  during  the  inflammatory  attack,  and 
thence  carried  by  the  current  to  the  heart  and  the  pulmonary  artery. 

B.  L.  E. 


Art.  XXVIII. — Report  on  Heating  and  Ventilation,  prepared  for  the  Trustees 
of  the  Johns  Hopkins  Hospital,  Baltimore.  By  John  S.  Billings,  Surgeon 
U.  S.  A.    8vo.,  pp.  93.    Baltimore,  1878. 

That  some  artificial  force  is  required  to  ventilate  a  hospital  effectually,  may 
now  be  regarded  as  a  settled  thing.  At  any  rate,  if  any  one  now  believes  that 
this  purpose  may  be  trusted  to  the  unassisted  powers  of  nature,  he  may  as  well 
be  left  to  the  enjoyment  of  his  opinion  unmolested  by  argument  or  evidence. 
But  something  more  than  a  recognition  of  the  principle  is  necessary  to  practical 
success.  It  is  not  enough  to  put  in  fans  and  steam  coils,  air  shafts,  and  chimneys, 
to  make  openings  for  the  fresh  air  to  come  in,  and  other  openings  for  the  foul  air 
to  go  out.  And  yet,  up  to  a  very  recent  period,  this  seems  to  have  been  regarded 
in  this  country  as  embracing  all  the  requirements  of  complete  hospital  ventilation. 
It  has  been  learned,  at  last,  that  the  various  arrangements  concerned  in  effecting 
the  interchange  of  air  must  be  prepared  under  a  system  of  exact  relations  to  one 
another.  Given  the  quantity  of  air  to  be  introduced,  we  have  then  to  calculate, 
for  instance,  the  size  and  velocity  of  the  fan,  the  size  of  the  shaft  through  which 
the  air  is  driven  to  the  heated  surfaces,  the  capacity  of  the  registers  by  which  it 
is  admitted  into  the  ward,  as  well  as  the  openings  by  which  it  escapes.  These  rela- 
tions must  all  be  ascertained  under  the  application  of  a  few  simple  rules  of  arith- 
metic and  mechanics,  and  the  results  verified  in  practice  by  means  of  instruments 
contrived  for  the  purpose.  When  these  various  appliances  are  constructed  at  hap- 
hazard, as  they  often  are,  we  have  no  right  to  charge  the  imperfect  result  that 
often  follows  upon  the  system  itself.  And  when  all  is  done,  there  is  need  of 
continued  intelligent  observation  of  the  working  of  the  system  under  the  varying 
conditions  of  the  atmosphere,  such  as  its  warmth  and  moisture,  the  force  and  direc- 
tion of  the  winds.  Much  of  Dr.  Billings's  report  is  occupied  with  this  latter 
branch  of  the  subject,  for  it  embraces  tables  of  observations  pursued  several  months 
together  in  the  Barnes  Hospital  connected  with  the  Soldiers'  Home  at  Washington, 
recording  the  inflow  and  outflow  of  the  air,  its  moisture  and  warmth,  the  force 
and  direction  of  the  wind,  the  height  of  the  mercury  in  the  barometer,  etc.,  and 
also  a  similar,  though  not  so  extensive,  series  of  observations  made  at  the  Boston 
City  Hospital,  the  former  by  Surgeon  D.  L.  Huntingdon,  U.  S.  A.,  the  latter 
by  Dr.  Cowles,  the  superintendent.  Dr.  Billings  justly  regards  these  as  "  the  best 
collection  of  such  observations  ever  made  in  this  country,"  and  although  too  few 
to  be  made  the  basis  of  any  fixed  rules  of  arrangement  or  practice,  yet,  as  he  says, 
"if  we  only  had  a  year's  careful  observations  from  the  Massachusetts  General 
Hospital ;  the  Presbyterian,  Roosevelt,  and  New  York  Hospitals,  of  New  York  ; 
the  Presbyterian,  Episcopal,  and  University  Hospitals,  of  Philadelphia ;  the 
Cincinnati  Hospital,  and  the  Cooke  County  Hospital,  of  Chicago,  similar  in  char- 
acter to  those  above  given,  we  should  have  the  data  for  a  treatise  on  hospital  heat- 
ing and  ventilation  that  would  be  really  valuable  and  useful." 

The  rest  of  the  Doctor's  report  is  occupied  with  some  of  the  details  of  the 
heating  and  ventilating  arrangements  which  he  designs  for  the  Johns  Hopkins 


524 


Bibliographical  Notices. 


[Oct. 


Hospital,  and  some  desultory  remarks  on  the  general  subject,  all  which,  as  being 
the  results  of  long  and  intelligent  study,  are  well  worthy  of  careful  consideration. 
A  perfect  system  of  ventilation  adapted  to  meet  all  exigencies  should  embrace, 
he  thinks,  both  fans  and  heated  aspirating  chimney  flues.  If  we  are  to  have  but 
one,  we  say,  let  it  be  the  fan,  but  it  would  also  be  well  to  utilize  the  heated  chim- 
neys which,  for  one  purpose  or  another,  are  always  to  be  found  in  hospitals. 

As  a  means  of  warming,  Dr.  Billings  prefers  hot  water  to  steam,  but  we  doubt 
that  the  few  advantages  attributed  to  it  offset  the  many  possessed  by  steam,  two  of 
which  seem  to  be  conclusive.  In  all  hospitals  steam  is  used  for  the  kitchen,  the 
laundry,  and  other  purposes,  and  certainly  it  must  be  an  additional  expense 
to  establish  and  maintain  in  connection  with  it  large  arrangements  for  heating 
water.  As  a  mode  of  heating  hospitals,  steam  is  preferable  also  on  the  score  of 
its  greater  flexibility.  There  are  many  days  in  the  year,  in  early  spring  and 
autumn,  when  a  little  artificial  heat  thrown  into  the  halls,  towards  evening  and 
on  damp  mornings,  is  very  grateful  to  the  patients.  With  steam  always  on  hand, 
this  may  be  speedily  done,  while  with  water  alone,  it  must  be  the  work  of  hours ; 
and  open  fires  in  the  wards  only  partially  answer  the  purpose,  desirable  as  they 
are  as  a  part  of  the  warming  system. 

The  report  also  embraces  two  reports  respecting  the  quantity  of  carbonic  acid 
in  the  air  of  hospital  wards,  one  from  Assistant  Surgeon  Mews,  and  the  other 
from  Professor  Edward  S.  Wood.  Their  analyses  prove  little  more  than  the  fact 
that  with  not  more  than  G  parts  of  carbonic  acid  in  10.000,  the  air  may  be  regarded 
as  tolerably  pure.  It  is  to  be  hoped  that  this  inquiry  will  be  prosecuted  further, 
because  it  is  intimately  connected  with  the  question  of  the  proper  height  of  the 
ceilings.  If,  other  things  being  equal,  the  purity  of  the  air  can  be  as  well  main- 
tained in  wards  twelve  feet  high,  as  in  wards  much  higher,  then  we  are  deprived 
of  a  prominent  argument  in  favour  of  one-story  wards  with  a  roof  twenty-five  or 
thirty  feet  above  the  floor.  And  surely  if  the  air  can  be  completely  renewed 
twice  as  often  in  one  ward  as  it  can  in  another  whose  cubical  contents  are  twice 
as  large,  the  chance  for  the  lodgment  of  disease  germs  is  lessened  in  the  same 
proportion.  Nothing  but  unquestionable  sanitary  advantages  can  warrant  a  mode 
of  hospital  construction  so  much  more  costly  in  the  outset,  and  in  which  the 
warming  and  the  ordinary  service  must  necessarily  be  more  expensive.  The 
Trustees  of  the  Johns  Hopkins  Hospital  can  scarcely  do  the  community  a  greater 
service  than  to  build  it-  at  the  smallest  possible  cost  consistent  with  the  attainment 
of  every  desirable  object.  In  this  time  of  distrust  and  dissatisfaction  about  the 
proper  cost  of  hospitals,  such  a  performance  would  prove  an  incalculable  help  to 
the  cause  of  humanity.  We  trust  that  their  conceptions  of  the  work  they  have 
undertaken  will  be  realized,  not  only  in  making  a  noble  provision  for  the  sick  and 
suffering  of  their  own  community,  but  also  in  furnishing  a  salutary  example  and 
lesson  to  other  communities  when  ready  to  engage  in  similar  work.         I.  R. 


Art.  XXIX.  —  The  Pathology  of  Pulmonary  Consumption.  Three  Lectures, 
by  T.  Hexry  Greex.  M.D.,  F.R.C.P.,  Physician  to  Charing-Cross  Hospi- 
tal, and  Assistant  Physician  to  the  Hospital  for  Consumption  and  Diseases  of 
the  Chest,  Brompton.    12mo.,  pp.  viii.,  103.    London:  Henry  Renshaw,  1878. 

The  part  which  inflammation  plays  in  the  production  of  phthisis  and  tubercu- 
losis continues  to  be,  in  spite  of  all  that  has  been  written  on  the  subject  during 
the  last  score  of  years,  one  of  the  vexed  questions  of  the  day.    The  experience 


1878.]        Green,  Pathology  of  Pulmonary  Consumption. 


525 


of  many,  if  not  the  majority  of  good  observers,  both  at  the  bedside  and  with  the 
microscope,  has  led  them  to  the  conclusion  that  most  of  the  lesions  of  the  condi- 
tions classed  under  these  heads  are  distinctly  traceable  to  inflammatory  processes. 
But  there  are  still  a  large  number  of  pathologists,  including  such  distinguished 
investigators  as  Reindfleisch  and  Wilson  Fox,  who  hold  that  the  disintegrative 
consolidation  of  the  lungs  in  phthisis  is  almost  invariably  associated  with  the 
development  of  a  specific  small-celled  growth  in  the  alveolar  walls,  which  they 
regard  as  tubercular,  and  that  inflammation  is  to  be  regarded,  when  unmistakably 
present,  as,  at  most,  an  accidental  concomitant. 

Dr.  Green,  in  the  Lectures  before  us,  endeavours  to  show  that  the  former  is 
the  correct  view  of  the  pathology  of  phthisis,  and  also  of  acute  miliary  tubercu- 
losis ;  for  between  these  two  conditions  he  can  detect  no  true  histological  differ- 
ence. It  would  be  impossible,  within  the  limits  of  a  notice  of  this  kind,  to  give 
in  detail  the  various  steps  in  the  arguments  by  which  he  supports  the  position  he 
has  taken.  We  must,  therefore,  content  ourselves  with  calling  attention  to  a 
few  of  its  leading  features. 

If  the  lungs,  in  the  various  forms  of  pulmonary  phthisis,  be  examined  micro- 
scopically, it  will  be  found,  Dr.  Green  says,  that  the  histological  changes  which 
have  taken  place  in  them  are  mainly  of  four  kinds  :  1 ,  the  presence  within  the 
pulmonary  alveoli  of  a  fibrous  exudation  and  leucocytes ;  2,  an  accumulation  of 
large  epithelial  cells  within  the  alveoli ;  3,  an  infiltration  and  thickening  of  the 
alveolar  walls  with  small  cells,  together  with,  in  most  cases,  a  similar  change  in 
the  walls  of  the  terminal  bronchioles  ;  and,  4,  an  increase  in  the  interlobular  con- 
nective tissues.  These  four  kinds  of  morbid  change  are  very  constantly  asso- 
ciated, although  in  very  different  degrees,  and  some  are  more  prominent  and 
characteristic  than  others.  Upon  the  preponderance  of  one  or  other  of  these 
mainly  depend  those  variations  in  the  physical  characters  of  the  lungs  which  are 
met  with  in  the  different  stages,  and  in  the  different  varieties  of  the  disease. 

In  those  forms  of  phthisis  in  which  the  process  is  of  maximum  intensity,  the 
consolidation  ot  the  lung  being  the  most  rapidly  induced,  exudation  and  emigra- 
tion may  occupy  a  prominent  place.  In  cases  of  somewhat  less  intensity,  epithe- 
lial proliferation,  accompanied  by  more  marked  changes  in  the  alveolar  walls, 
will  take  a  large  share  in  the  production  of  the  consolidation,  whilst  in  those  cases 
in  which  the  inflammatory  process  is  least  intense  and  most  chronic,  the  groAvth 
in  the  alveolar  walls  and  interlobular  tissue  will  constitute  the  predominant 
lesions. 

The  author  then  proceeds  to  show  that  all  the  above-named  changes  occur  in 
morbid  conditions  of  the  lungs  which  do  not  come  within  the  category  of  phthisis, 
and  the  pathology  of  which  is  comparatively  well  understood.  For  instance,  the 
exudation  products,  which,  although  less  frequently  met  with  than  the  other 
forms  of  lesion,  often  constitute,  in  his  opinion,  an  important  element  in  the  dis- 
ease, are  indistinguishable  from  those  that  are  found  filling  the  alveoli  in  ordinary 
acute  croupous  pneumonia.  Again,  the  proliferation  and  accumulation  of  epithe- 
lial cells  within  the  pulmonary  alveoli,  which  he  describes  as  occurring  in  phthisis, 
are  also  observed  in  catarrhal  pneumonia.  A  certain  amount  of  epithelial  prolife- 
ration also  frequently  takes  place  in  croupous  pneumonia,  and  especially  in  the 
secondary  pneumonias,  which  are  often  met  with  as  the  acute  process  terminating 
a  chronic  disease.  The  cellular  infiltration  of  the  alveolar  walls,  although  less 
frequently  met  with  in  non-phthisical  and  non-tubercular  forms  of  pulmonary  dis- 
ease than  the  other  changes  occurring  in  phthisis,  and,  therefore,  most  charac- 
teristic of  this  condition,  js  occasionally  seen  in,  1st,  cases  of  ordinary  pneumonia, 
in  which  the  exudation  products  are  not  readily  absorbed,  and  in  which  the  con- 
dition becomes  more  or  less  chronic  *,  2d,  those  conditions  of  the  lungs,  of  which 


526 


Bibliographical  Notices. 


[Oct. 


Corrigan's  cirrhosis  may  be  taken  as  the  type  ;  and,  3d,  many  cases  of  lonc-con- 
tinued  bronchial  catarrh.  Virchow,  also,  long  ago  pointed  out  the  richly  cellular 
character  of  the  products  of  scrofulous  inflammations,  the  tendency  to  cellular  infil- 
tration of  the  tissues,  and  the  extreme  tardiness  with  which  the  infiltration  becomes 
absorbed.  It  need  scarcely  be  added  that  an  increase  in  the  interlobular  connec- 
tive tissue  occurs  in  all  conditions  of  long-continued  pulmonary  irritation,  and 
that  it  reaches  its  maximum  in  Corrigan's  cirrhosis. 

The  giant-cells,  which  are  regarded  by  many  observers  as  a  characteristic 
microscopical  appearance  in  phthisis  and  tuberculosis,  are  identical,  in  the  author's 
opinion,  with  the  large  cells  found  in  scrofulous  inflammation,  and  are  to  be 
looked  upon  as  "the  result  of  an  inflammatory  process  of  slight  intensity,  occur- 
ring in  tissues  of  such  low  vitality  that  the  cellular  inflammatory  products  are 
incapable  of  forming  an  organized  tissue,  but  merely  undergo  some  increase  in 
size,  and  then  tend  to  slowly  degenerate.  The  protoplasm  grows,  the  nuclei 
multiply,  but  that  higher  manifestation  of  vitality,  the  division  of  the  cell,  does 
not  take  place." 

We  have  already  alluded  to  the  fact  that  Dr.  Green  teaches  that  the  changes 
in  the  lungs  in  pulmonary  phthisis  are  similar,  histologically,  to  those  which  occur 
in  acute  miliary  tuberculosis.  They  differ,  however,  he  says,  in  two  particulars. 
In  the  first  place,  whereas  the  lesions  in  acute  tuberculosis,  owing  to  the  infective 
character  of  the  disease — for  he  adopt' s  Buhl's  view  of  its  pathology — tend  to  be 
limited  to  small,  circumscribed  areas ;  those  of  phthisis  more  commonly  involve 
wider  and  more  diffused  tracts  of  tissue.  Secondly,  inasmuch  as  phthisis  usually 
runs  a  much  more  protracted  course  than  acute  tuberculosis,  the  lesions  not  only 
become  more  densely  fibroid,  but  they  are  also  frequently  the  seat  of  secondary 
changes. 

These  Lectures  are  well  written ;  the  illustrations  are  well  executed ;  and  to 
us  Pr.  Green's  reasoning  seems  convincing.  J.  H.  H. 


Art.  XXX. — Die  Enstehung  der  Gefdhr  in  Kranlcheitsverlaufe,  mit  Beson- 
derer  Berucklichtigung  der  Diagnose  der  Gefahr,  Hirer  Prophylaxe,  und 
Therapie.  Yon  Dr.  L.  M.  Politzer,  A.  O.  Professor,  Director  der  Ersten 
Oflentlichen  Kinderkrankeninstitutes  in  Wien.  8vo.,  pp.  xx.,  395.  Wien  : 
Wilhelm  Braumliller,  1878. 

The  Occurrence  of  Danger  in  the  Course  of  Disease,  icith  Special  Reference 
to  the  Recognition  of  the  Danger,  its  Prophylaxis,  and  Therapeutics.  By 
L.  M.  Politzer,  Director  of  the  Children's  Hospital  in  Vienna,  etc. 

Much  of  our  want  of  success  in  the  treatment  of  disease  is  due,  Dr.  Politzer 
believes,  to  an  insufficient  appreciation  in  the  course  of  disease  of  symptoms 
which  indicate  the  beginning  of  danger.  While  the  teacher  at  the  bedside  and 
writers  of  systematic  treatises  on  disease  take  great  pains  to  train  the  student  in 
the  art  of  diagnosis,  but  little  attention  is  paid,  he  thinks,  to  prognosis.  And 
yet  it  is  evident  that,  unless  we  are  able  at  once  to  recognize  the  approach  of 
danger  even  though  afar  off,  we  shall  not  only  often  fail  in  our  efforts  to  bring 
the  disease  to  a  favourable  termination,  but  may  often  find  a  patient  in  a  collapse 
whom  a  few  hours  before  we  had  left  apparently  doing  well.  The  subject  is  in- 
deed an  important  one,  but  we  can  scarcely  agree  with  our  author  in  thinking  it 
wholly  neglected.  Certainly  in  this  country  the  majority  of  intelligent  practi- 
tioners are  keenly  alive  to  the  dangers  which  the  author  refers  to,  and  we  know 


1878.] 


B  u  s  e  y  ,  Dilatation  of  Lymph  Channels. 


527 


that  it  is  quite  common  for  clinical  lecturers  to  point  out  the  necessity  of  being 
constantly  on  the  lookout  for  accidents  and  complications  in  the  course  of  disease. 

Among  the  signs  of  danger  none  are  of  greater  importance  than  those  which 
indicate  the  presence  of  commencing  paralysis  of  the  heart  and  of  the  respiratory 
centre  in  the  medulla  oblongata,  and  when  these  are  observed — no  matter  how 
little  marked  they  may  be — they  should  be  at  once  met  with  appropriate  treat- 
ment. Nothing  is  more  likely  to  produce  paralysis  of  the  heart  and  of  the  respi- 
ratory centre  than  long-continued  fever  ;  and  although  the  author  fully  recognizes 
the  fact  that  high  temperature  does  not  alone  constitute  fever,  and  that  all  the 
lesions  of  fever  are  not  due  to  it  solely,  he  is  nevertheless  fully  convinced  of  the 
necessity  of  moderating  it  whenever  this  is  possible.  He  therefore  raises  his 
voice  against  a  purely  expectant  plan  of  treatment  in  fevers,  by  which,  in  his 
opinion,  many  lives  have  been  sacrificed,  and  urges  upon  us  the  use  of  the  cold 
bath,  bv  means  of  which  we  have  it  in  our  power  generally  to  convert  a  high 
degree  of  fever  into  a  low  one.  All  the  good  effects  of  the  cold  bath  are  not, 
however,  to  be  referred  to  its  powerful  influence  in  reducing  the  temperature  of 
the  body.  By  its  sudden  action  on  the  cutaneous  nerves,  the  central  organs  of 
innervation  are  aroused  from  their  torpor.  In  this  way  the  author  explains  the 
improvement  in  the  mental  condition  of  a  fever  patient,  which  often  immediately 
follows  his  immersion  in  a  cold  bath,  or  before  any  considerable  reduction  in  his 
temperature  can  have  taken  place.  He  recommends,  however,  the  use  of  the 
cold  bath  not  merely  in  long-continued  fevers  with  high  temperatures,  but  in  the 
beginning  of  the  treatment  of  scarlatina  maligna  and  of  other  diseases  of  this 
class.  It  may  also  be  used  with  advantage  in  the  management  of  so  simple  a 
disease  as  tonsillitis,  in  which  we  shall  often  by  its  use  prevent  the  occurrence  of 
the  prostration  which  often  succeeds  to  this  condition,  and  which  can  only  be 
attributed  to  the  high  fever  which  generally  accompanies  it. 

The  special  dangers  which  occur  in  the  course  of  chronic  diseases  are  also  care- 
fully pointed  out  by  the  author,  and  so  are  the  means  by  which  the  physician  is 
to  avoid  them.  As  these  are  to  be  found  in  every  text-book,  it  seems  unneces- 
sary to  call  special  attention  to  them  here.  J.  H.  H. 


Art.  XXXI. —  Congenital  Occlusion  and  Dilatation  of  Lymph  Channels. 
By  Samuel  C.  Busey,  M.D.,  Professor  of  Theory  and  Practice  of  Medicine 
in  University  of  Georgetown,  etc.  8vo.,  pp.  xvi.,  187.  New  York:  Wm, 
Wood  &  Co.,  1878. 

How  great  a  fire  a  little  matter  kindleth  is  well  seen  in  this  book.  The  author 
had  under  his  care  a  single  case  with  which  the  volume  opens  ;  became  interested 
in  studying  the  subject,  ransacked  the  literature  of  all  nations,  and  has  gathered 
together  eighty-seven  other  cases,  given  usually  with  some  fulness,  and  illustrated 
by  fifty-six  engravings.  In  his  preface  he  acknowledges  fittingly  his  obligations 
to  Dr.  Billings  and  the  National  Medical  Library.  Indeed  such  a  book  could  not 
have  been  written  before  the  existence  of  this  library  and  the  extraordinarily 
useful  and  elaborate  subject-catalogue  prepared  in  connection  with  it. 

.  The  book  consists  practically  of  a  series  of  articles  contributed  to  the  American 
Journal  of  Obstetrics,  and  is  supplemented  by  a  similar  series,  published  in  the 
Neiv  Orleans  Medical  and  Surgical  Journal,  on  the  acquired  varieties  of  the 
disease.  The  two  constitute  a  valuable  contribution  to  an  obscure  subject,  involv- 
ing an  immense  amount  of  research,  ' '  while  never  neglecting  a  busy  practice,  and 


528 


Bibliographical  Notices. 


[Oct. 


for  the  most  part  during  the  hours  usually  appropriated  to  recreation  and  sleep" — 
an  example  of  industry  and  zeal  for  many  a  young  doctor  not  overburdened  with 
patients,  if  not  to  the  traditional  "busy  practitioner."' 

To  analyze  the  book  would  be  largely  to  reproduce  it,  and  we  must  refer  those 
interested  in  the  subject  to  the  text  itself.  It  consists  essentially  of  the  narration 
of  the  collected  cases  grouped  together  clinically,  and  followed  by  a  running  com- 
mentary. At  the  end  are  placed  some  "General  Remarks"  and  a  section  on 
"Treatment."  This,  whether  constitutional  or  local,  medical  or  surgical,  is 
naturally  unsatisfactory,  for  the  disease  is  but  little  amenable  to  treatment  other 
than  amputation — where  this  is  practicable. 

The  book  has  one  serious  defect  as  it  seems  to  us.  With  such  a  mass  of  ma- 
terial the  subject  might  have  been  treated  systematically,  giving  its  pathology  j 
etiology,  description,  diagnosis,  prognosis,  and  treatment  under  appropriate  head- 
ings, using  such  typical  cases  as  might  be  selected,  and  grouping  the  remaining 
cases,  to  which  reference  could  be  made,  at  the  end.  Students  of  the  subject 
would  thus  have  been  able  to  obtain  succinctly  a  more  accurate  idea  of  the  dis- 
ease. As  the  book  is  arranged  it  is  essential  to  read  it  all,  and  moreover  one  will 
rise  from  its  reading  without  such  crystallized  and  sharply-cut  notions  as  an 
author  who  has  carefully  studied  the  subject  can  readily  formulate  in  well-chosen 
words.  The  author  pleads  in  excuse  that  he  has  desired  to  present  the  subject 
clinically.  But  after  all  a  book  is  intended  to  impart  useful  information,  and  we 
think  the  end  would  have  been  better  attained  had  the  book  been  recast  in  the 
form  we  have  suggested.  W.  W.  K 

  % 

Art.  XXXII. — The  Antidotal  Treatment  of  Disease.  By  John  Parkin,  M.D., 
Corresponding  Fellow  of  the  Royal  Academies  of  Medicine  and  Surgery  of 
Madrid,  of  Barcelona,  and  of  Cadiz;  F.R.C.P.  Edinburgh,  etc.  Part  I. 
8vo.,  pp.  307.    London:  Hardwicke  and  Boyne,  1878. 

If  it  be  obvious  that  all  criticism  of  books  involves  a  twofold  duty,  towards 
authors  and  towards  those  who  read,  it  will  appear  also  that  the  principle  of 
the  greatest  good  to  the  greatest  number  makes  paramount  the  reviewer's  duty 
towards  readers.  Granting  this,  three  kinds  or  classes  of  books  may  be  named, 
which  will  include  all:  first,  those  which  every  one  must  read  if  he  would  not 
fall  entirely  behind  his  times;  secondly,  those  which  any  one  may  read,  who  has 
abundant  leisure,  and  special  interest  in  its  subject ;  and  thirdly,  those  which  no 
one  ought  to  waste  time  upon  under  any  circumstances. 

We  believe  it  not  unjust  to  Dr.  Parkin's  book  to  place  it  in  the  second  of  these 
categories.  It  gives  evidence  of  considerable  research  in  regard  to  the  history  of 
medical  systems  and  theories  ;  and  a  commendable  acquaintance  with  recent  path- 
ological and  therapeutical  investigations.  The  characteristic  matter  of  the  book, 
however,  consists  in  three  ideas  or  opinions  of  the  author,  with  a  number  of  clin- 
ical facts  interpreted  by  him  as  supporting  them.  The  first  of  these  opinions  is, 
that  "the  majority  of  fevers — all  specific  or  essential  fevers — are  the  product  of 
one  particular  agent,  viz.,  malaria."  In  this  identity  of  causation  Dr.  Parkin  in- 
cludes intermittent  and  rc  mittent  fever,  yellow  fever,  typhus,  (probably)  typhoid, 
puerperal  fever,  smallpox,  scarlet  fever,  and  measles  ;  repudiating  the  1 '  theory  of 
contagion"  altogether  (p.  298). 

His  second  peculiarity  lies  in  the  pathological  domain.  He  holds  that  the  symp- 
toms of  all  fevers  are  due  to  the  presence  of  the  malarial  poison  in  the  cajnllaries, 


1878.] 


Logan,  Physics  of  the  Infectious  Diseases. 


529 


systemic  and  pulmonary  ;  its  action  being  "  due,  solely  and  entirely,  to  the  toxic 
effect  of  the  morbid  matter  on  the  nervous  system"  (p.  103). 

Lastly,  that  which  justifies  the  title  of  the  book,  "The  Antidotal  Treatment 
of  Fever,"  is  the  assertion,  that  carbonic  acid,  given  especially  during  the  cold 
stage,  is  the  antidote  for  all  forms  of  fever.  The  manner  in  which  Dr.  Parkin 
adduces  facts  to  support  this  view,  not  only  from  his  own  experimental  medica- 
tion in  practice,  but  from  that  of  others,  and  from  familiar  medical  records,  is 
that  of  an  earnest  as  well  as  ingenious  advocate.  Effervescing  draughts,  com- 
monly regarded  as  agreeable  palliative,  minor  remedies,  are  by  our  author  pro- 
moted to  the  rank  of  therapeutic  agents  in  chief ;  heroic,  though  so  gentle  ; 
•■  suaviter  in  modo,  fortiter  in  re."  All  other  agencies  in  therapeutics  are,  with 
him,  to  be  extinguished  by  this  gas.  Champagne  must  now  be  understood  to  do 
good  in  yellow  fever  and  typhus,  not  through  its  alcoholic  constituent,  but  by  its 
effervescence.  Quinia  Dr.  Parkin  believes  to  be  too  uncertain,  and  often  in- 
jurious, to  be  given  longer  in  intermittent ;  carbonic  acid  must  take  its  place. 

These  are  assertions  not  only  of  opinion,  but  also  concerning  clinical  facts. 
Only  by  clinical  experience,  carefully  and  largely  tested,  can  they  be  proved  or 
disproved.  If  we  share  with  many,  probably  most  of  our  readers,  very  strong- 
doubts  as  to  the  exactness  of  Dr.  Parkin's  interpretations,  and  the  soundness  of 
his  practical  conclusions,  his  appeal  has  been  made  to  experience ;  and  that 
appeal  must,  of  course,  be  sustained.  H.  H. 


4 

Art.  XXXIII. — Physics  of  the  Infectious  Diseases.  Comprehending  a  Dis- 
cussion of  Certain  Physical  Phenomena  in  Connection  with  the  Acute  Infec- 
tious Diseases.  By  C.  A.  Logan,  A.M.,  M.D.  12mo.  pp.  212.  Chicago: 
Jansen,  McClurg  &  Co.,  1878. 

A  long  residence  on  the  western  coast  of  South  America  has  led  Dr.  Logan 
to  notice  certain  remarkable  facts  as  to  the  non-existence  of  some  infectious  dis- 
eases, and  the  modification  of  others,  in  large  portions  of  that  volcanic  belt  of 
land. 

The  old  theory,  that  earthquakes  and  volcanic  eruptions  are  mere  mechanical 
activities  of  the  boiling  and  bubbling  molten  matter  under  the  earth's  crust,  is 
entirely  discarded  by  Dr.  Logan.  Electric  disturbance,  or  rather  perhaps  the 
restoring  of  electric  equilibrium,  is  believed  to  be  the  cause  of  the  phenomena  in 
question.  Regular  thunder-storms  are  rare  in  the  earthquake  region.  Preceding 
the  convulsions,  displays  of  electric  lights  in  the  heavens  are  quite  common.  The 
magnetic  needle  is  affected,  and  the  hair  of  animals  is  charged  with  electricity. 
Peculiar  oppression,  or  other  strange  sensations  of  the  nervous  system,  are 
noticed.  A  peculiar  state  of  the  atmosphere  is  often  remarked.  Meteorites  are 
frequently  unusually  abundant.  The  production  of  rain  and  of  ozone  also  point 
to  electric  action  as  the  essence  of  the  phenomena. 

Having  briefly  noted  some  of  the  peculiarities  of  the  region,  as  stated  and  inter- 
preted by  our  writer,  we  will  now  pass  to  the  special  characteristics  of  disease  as 
there  existent. 

Whatever  may  be  thought  of  Dr.  Logan's  reasoning,  his  statements  as  to  the 
absence  or  modification  of  epidemic  diseases  on  the  west  coast  of  South  America 
are  sufficiently  startling  to  secure  attention  and  elicit  thought.  The  value  of 
facts  is  not  destroyed  by  any  lack  of  skill  in  their  interpretation. 

Throughout  the  rainless  regions,  and  those  where  the  waterfall  is  purely  sea- 
No.  CLII  Oct.  1878.  34 


530 


Bibliographical  Notices. 


[Oct. 


sonal — subject,  as  we  have  seen,  to  frequent  earthquakes — a  large  number  of 
those  infectious  diseases  which  devastate  other  countries  are  practically  unknown. 
And  our  author  adds,  with  less  positiveness,  that  where  a  rainy  season  exists  such 
diseases  prevail,  if  at  all,  especially  during  that  season,  when  the  shocks  have 

ceased  for  the  year. 

The  absence  of  these  general  scourges  of  mankind  from  large  portions  of  the 
western  coast  of  South  America  is  not  due  to  lack  of  facilities  for  importing  the 
infectious  principles.  Commercial  intercourse  with  the  world  at  large,  and  even 
with  neighbouring  countries  afflicted  with  cholera  and  with  yellow  fever,  is  con- 
stant and  wholly  unrestricted.  Nor  is  lack  of  humidity  the  cause  of  this  exemp- 
tion. Not  only  are  some  of  the  favoured  regions  well  watered  by  mountain 
streams,  but  they  are  also  recipients  of  moisture  from  the  sea,  and  the  seat  of 
extremely  heavy  dews.  Mildew  and  rust  are  common  annoyances  where  rain  is 
unknown.  Indeed  there  are  some  places  possessing  copious  seasonal  rains  which 
share  with  the  rainless  districts  an  exemption  from  the  zymotics.  The  one  par- 
ticular in  which  all  agree  is  the  existence  of  constant  shocks  and  eruptions — re- 
garded by  Dr.  Logan  as  manifestations  of  intense  electric  disturbance. 

Cholera  and  yellow  fever  are  reported  to  be  wholly  absent  from  the  southern 
three-fourths  of  the  western  slope  ;  and  of  very  doubtful  existence  near  the 
equator.  Scarlatina  has  been  reported  to  have  occurred  in  certain  localities;  but 
it  has  acquired  no  foothold  whatever  in  any  part  of  this  extended  but  narrow 
strip.  Neither  of  the  great  continued  fevers,  typhus  or  typhoid,  is  known  at 
all.  Diphtheria  and  "hay-fever"  are  equally  absent.  Cerebro-spinal  meningitis 
and  relapsing  fever  may  possibly  have  appeared  to  a  very  limited  extent. 

Variola  is  stated  to  become  so  changed  by  local  influences  as  to  almost  lose  its 
identity.  Among  the  filth  and  wretchedness  of  the  poor  in  the  Chilian  cities  it 
constantly  abides,  and  at  intervals  acquires  the  character  of  an  epidemic.  It 
then  proves  terribly  fatal ;  but  never  leaves  the  cities,  nor,  indeed,  does  it  often 
extend  outside  of  the  lowest  slums  in  which  it  arises.  The  disease  differs  here 
from  that  of  other  lands  in  several  points ;  but  the  most  important  are  the  ineffi- 
caey  of  vaccination,  and  the  liability  to  attack  the  same  patient  repeatedly.  All 
possible  means  have  been  tried  to  secure  the  best  lymph,  surrounded  by  all  pos- 
sible precautions  against  deterioration  ;  but  no  protective  influence  follows  its 
use.  We  are  not  informed  as  to  the  course  of  the  vaccination  wound.  The 
change  of  type  here  noted  is  said  to  obtain  in  Peru  as  well  as  Chili. 

Syphilis  prevails  to  a  fearful  extent.  Erysipelas  becomes  epidemic  at  times, 
assuming  hemorrhagic  and  gangrenous  forms,  and  causing  great  mortality.  In 
puerperal  women  it  takes  the  shape  of  metro-peritonitis.  Dysentery  is  common, 
especially  among  the  poor.  Influenza  has  not  unfrequently  apj^eared  as  an  epi- 
demic, almost  simultaneously  at  distant  points. 

One  malady  is  noticed  as  peculiar  to  Chili — the  chabalonga.  This  at  times 
becomes  epidemic,  especially  among  the  lowest  classes,  visiting  the  better  classes 
mildly  if  at  all.  It  seems  to  be  a  product  of  filth  and  wretchedness.  There  is 
.no  eruption.  The  name  comes  from  a  characteristic  sequel — the  falling  of  the 
hair.  Some  physicians  have  regarded  it  as  identical  with  typhus,  as  that  appeared 
among  the  Irish  peasantry. 

A  peculiar  fever,  with  warty  eruptions,  appeared  in  Peru  among  labourers 
engaged  in  building  a  railroad  through  soil  never  before  disturbed  by  man,  among 
the  Andesi.  Some  claim  that  it  has  previously  appeared  under  similar  conditions. 
The  tubercles  are  from  the  size  of  a  pea  nearly  to  that  of  a  hen's  egg.  They 
tend  to  bleed  profusely.  Stimulants  and  tonics  were  employed  ;  but  neither  in 
ithis  affection  nor  in  the  chabalonga  did  quinia  exhibit  specific  powers. 

We  ought  perhaps  to  have  earlier  drawn  attention  to  the  remarkable  fact,  that 


1878.] 


Duheixg,  Atlas  of  Skin  Diseases, 


531 


the  large  cities  of  this  coast,  so  wonderfully  free  from  the  maladies  -which  ordi- 
narily bear  with  especial  severity  upon  the  crowded  masses  of  the  poor,  are 
abominably  deficient  in  the  sanitary  conditions  generally  thought  essential  to 
secure  reasonable  freedom  from  fatal  epidemics.  In  most  cases  the  lower  classes 
are  ignorant,  shiftless,  and  vicious,  and  living  in  the  most  deplorable  extremes  of 
bad  diet,  bad  drainage,  and  unwholesome  surroundings.  The  character  and 
course  of  the  diseases  which  do  prevail,  indicate  the  constitutional  weakness  and 
depression  of  vitality  that  might  be  expected  under  such  circumstances.  Some 
especial  cause,  therefore,  must  exist  for  the  absence  of  the  infectious  diseases  of 
other  regions.  This  Dr.  Logan  is  disposed  to  find  in  the  peculiar  electric  or 
magnetic  conditions  of  the  locality — of  which  the  startling  mechanical  phenomena 
of  the  coast  are  the  token  and  expression.  The  effect  of  electricity  on  chemical 
and  vital  action  is  referred  to  at  considerable  length.  The  author's  line  of  thought 
may  be  suggested  by  one  of  his  illustrations  ;  if  chemical  change  in  fresh,  pure 
milk  is  almost  instantly  brought  about  by  a  thunder-storm,  why  may  not  the 
formation  of  toxic  compounds,  or  the  development  of  certain  organic  germs,  be 
equally  as  strictly  dependent  on  electric  conditions  ?  Accordingly,  he  believes 
that  electric  energy  may  and  does  decompose  "the  infectious  molecule,"  byre- 
arrangement  of  atoms  or  their  dispersal.  That  action  of  ozone,  which  we  desig- 
nate as  antiseptic  or  disinfectant,  is  probably  as  yet  but  partially  appreciated. 
And  a  free  evolution  of  this  agent  is  known  to  attend  telluric  convulsions,  as  it 
undoubtedly  does  forms  of  electric  activity.  A  peculiar  odour,  pretty  certainly 
that  of  ozone,  has  in  all  times  and  countries  been  observed  in  connection  with 
earthquake  shocks,  and  with  the  so-called  "stroke  of  lightning." 

In  respect  as  it  describes  the  diseases  peculiar  to  a  region  but  little  known  to 
the  European  and  American  profession,  the  modifications  of  smallpox  there 
observed,  and  the  extraordinary  exemption  from  several  of  the  most  destructive 
of  the  acute  infectious  diseases  prevailing  elsewhere — this  book  possesses  great 
interest  for  all.  As  to  the  peculiar  speculations  of  the  writer  there  may  be  room 
for  a  diversity  of  opinion ;  but  even  those  who  may  be  unable  wholly  to  follow 
him,  cannot  fail  to  recognize  the  value  of  his  suggestions  as  food  for  thought,  and 
as  providing  possibly  the  seeds  for  harvests  in  the  future.  B.  L.  R. 


Art.  XXXIV. — Atlas  of  Skin  Diseases.  By  Louis  A.  Duhrixg,  M.D., 
Professor  of  Skin  Diseases  in  the  Hospital  of  the  University  of  Pennsylvania  ; 
Physician  to  the  Dispensary  for  Skin  Diseases,  Philadelphia,  etc.  Part  IV. 
Philadelphia:  J.  B.  Lippincott  &  Co.,  1878. 

This  part  appears  with  commendable  promptness,  and  sustains  in  all  respects 
the  favourable  opinion  we  have  so  recently  expressed.  The  diseases  illustrated 
are:  Vitiligo,  Alopecia  areata,  Tinea  favosa,  and  Eczema  (rubrum).  The  first 
three  are  somewhat  rare  affections,  but  their  recognition  by  the  practitioner  is  of 
importance,  and  will  be  rendered  easier  by  the  typical  representations  here  given. 
The  last  picture,  infantile  acute  eczema,  shows  one  of  the  most  common  and 
vexatious  diseases  in  all  its  characteristic  diversity  of  efflorescence. 

The  artist  has  apparently  so  guarded  his  effects  against  exaggeration  that  the 
colouring  in  some  portions  of  this  latter  plate  and  that  of  favus  might  be  made 
considerably  more  brilliant  in  parts  without  surpassing  nature. 

The  accompanving  text  preserves  its  previous  high  standard  of  simple  excel- 
lence.        -        -        -  ~  J.  c.  w. 


532 


Bibliographical  Notices. 


[Oct. 


Art.  XXXV. — Anatomy,  Descriptive  and  Surgical.  By  Henry  Gray, 
F.R.S.  With  an  Introduction  on  General  Anatomy  and  Development.  By 
T.  Holmes.  A  new  American  from  the  eighth  English  edition.  To  which  is 
added  Landmarks,  Medical  and  Surgical.  By  Lutheb  Holdkx.  F.R.C.S. 
Imperial  8vo.  pp.  983.    Philadelphia:  H.  C.  Lea,  1878. 

The  appearance  of  a  new  American  edition  of  that  well-known  text-book, 
"Gray's  Anatomy,"  is  a  matter  of  congratulation.  Since  the  last  reprint  here, 
three  new  additions  have  appeared  in  England,  in  which  the  minuter  anatomy  of 
the  ear  and  the  kidney  have  been  corrected,  and  the  introductory  chapter  has 
been  corrected  and  enlarged.  Dr.  Dunglison's  exactness  of  revision  and  judi- 
cious selection  of  a  few  additional  plates  are  also  worthy  of  note. 

But  the  most  important  difference  between  this  and  former  editions  is  that 
Holden's  book  on  "Landmarks"  has  been  incorporated  in  the  volume,  making, 
in  fact,  two  books  in  one,  and  this  without  any  increase  of  the  price.  This  is 
practically  the  anatomy  that  is  most  needed  at  the  bedside,  and  cannot  be  too 
carefully  studied  and  mastered  bv  both  the  physician  and  the  surgeon. 

W.  W.  K. 


Art.  XXXVI. — Abbreviations  of  Titles  of  Medical  Periodicals  to  be  used  in 
the  Subject-Catalogue  of  the  Library  of  the  Surg  eon- General s  Office.  Im- 
perial 8vo.  pp.  vi.,  96.    Washington:  Government  Printing  Office,  1878. 

More  than  two  years  ago,  we  had  the  pleasant  task  of  inviting  our  readers' 
attention  to  a  "Specimen-Fasciculus"  of  the  long-expected  Subject-Catalogue  of 
the  National  Medical  Library  at  Washington,  and  the  truth  of  the  Hippocratic 
aphorism  is  now  forcibly  brought  to  our  mind  by  finding  that,  though  the  bien- 
nium  has  slipped  by,  the  manuscript  of  the  Catalogue  is  still  in  "preparation." 

The  list  of  abbreviations,  which  is  now  before  us,  is  designed,  as  we  learn  from 
Dr.  Billings's  prefatory  remarks,  partly  as  a  means  of  obtaining  criticisms  and  sug- 
gestions, and  partly  as  a  matter  of  convenience  in  preparing  the  Catalogue  itself 
for  the  press.  The  principles  observed  in  the  adoption  of  the  abbreviations  have 
been  (1)  to  follow  the  exact  order  of  the  words  of  the  title  ;  (2)  to  make  the  abbre- 
viations as  brief  as  was  consistent  with  clearness  ;  (3)  to  follow  strictly  the  ortho- 
graphical usages  of  each  language ;  and  (4)  to  attain  uniformity,  when  possible 
without  obscurity.  We  are  glad  to  learn  that  the  work  of  indexing  Journals  and 
Transactions  deemed  worthy  of  the  labour  has  been  completed,  except  as  regards 
certain  special  branches  of  Medical  Science,  and  that  hence  no  delay  from  this 
source  may  be  expected  to  hinder  the  early  appearance  of  the  much  wished-for 
volumes. 

As  concerns  the  abbreviations  adopted,  such  examination  as  we  have  been  able 
to  give  leads  us  to  believe  that  they  are  judiciously  framed,  and  well  adapted  for 
their  purpose  ;  we  have  certainly  neither  criticisms  nor  suggestions  for  improve- 
ment to  offer  to  the  learned  Librarian  of  the  Surgeon-General's  Office  in  this 
matter.  We  would  venture  to  express  a  hope,  and  in  this  we  are  sure  that  we 
represent  the  feeling  of  all  our  readers,  that  our  legislators  in  Congress  may,  during 
the  coming  session,  think  proper  to  make  the  needful  appropriations  for  printing 
the  Catalogue  in  the  style  which  it  merits,  and  thus  confer  an  almost  inestimable 
boon  upon  the  Medical  Profession,  not  only  of  our  own  but  also  of  other  countries, 
and  thus  indirectly,  but  not  remotely,  upon  the  whole  community,  and  indeed 
upon  the  whole  civilized  world.  J.  A.,  Jr. 


1878.] 


533 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES 

IN  THE 

MEDICAL  SCIENCES. 


ANATOMY  AND  PHYSIOLOGY. 

On  the  Relative  Size  of  the  Trachea  and  Bronchia. 
M.  Marc  See  gives  the  following  results  of  his  experiments,  in  a  paper  read 
before  the  Academie  de  Medecine : — 

(1)  The  mean  diameter  of  the  trachea  is  generally  larger  in  the  male  than  in 
the  female  of  the  same  age.  It  increases  with  age.  It  was  3|  millimetres  in  a 
foetus  of  seven  months  and  a  half.  At  birth  it  varies  from  4  mm.  to  5.6  mm. 
At  the  age  of  two  years  it  is  7.5  mm.  and  even  8  mm.  From  four  to  seven  years 
the  diameters  are  from  8  mm.  to  10.5  mm.  Below  the  age  of  twenty  the  num- 
bers vary  between  16  mm.  and  22.5  mm.  in  the  male,  in  females  between  13 
mm.  and  16  mm.  The  average  in  twenty-one  adult  male  subjects  was  18  mm., 
in  twelve  adult  female  subjects  14.5  mm. 

(2)  The  mean  diameter  of  the  right  bronchia  in  subjects  under  twenty  years  of 
age  varies  between  11.75  mm.  and  17,5  mm.  The  average  of  eighteen  male  sub- 
jects was  14  mm.,  that  of  twelve  females  12  mm. 

(3)  The  mean  diameter  of  the  left  bronchia  varies  in  subjects  over  twenty 
years  between  7  mm.  and  13.5  mm.  The  average  of  eighteen  male  subjects  was 
11.6  mm.,  that  of  twelve  female  subjects  9  mm. 

(4)  The  cube  of  the  diameter  of  the  trachea,  as  compared  with  the  united 
cubes  of  the  diameters  of  the  bronchi,  gave  similar  numbers  in  twenty-five  cases. 
These  cases  comprehend  :  (a)  Subjects  to  the  number  of  thirteen,  of  either  sex, 
above  twenty  years  of  age  (with  the  exception  of  one  boy  aged  four,  who  died  of 
croup),  in  all  of  whom  the  size  of  the  trachea  surpassed  greatly  the  average  size 
of  the  two  bronchia,  72.25  mm.,  against  52.60  mm.  In  almost  all  these  subjects 
the  pulse  was  healthy.  A  boy  of  five  died  of  tubercular  pneumonia,  two  others 
of  the  same  age  of  croup.  (&)  Twelve  subjects  above  twenty  years,  of  whom 
eight  had  healthy  lungs,  and  amongst  the  latter  was  an  old  man  of  eighty-six. 
The  remaining  four  were — a  man  of  twenty-one,  and  a  woman  of  thirty  years  of 
age,  both  deceased  from  tubercular  phthisis ;  a  man  thirty-two,  affected  with  sup- 
purating pneumonia  ;  and  another  of  forty-five,  in  all  of  whom  there  was  dilatation 
of  the  bronchia.  The  same  uniformity  showed  itself  in  dogs,  and  in  a  sheep 
examined  by  M.  See  for  this  purpose. 

(5)  The  size  of  the  trachea  was  smaller  than  that  of  the  two  bronchia  in  eight 
subjects,  of  whom  five  had  a  very  extensive  tuberculization  of  the  lungs  ;  whilst 


534 


Progress  of  the  Medical  Sciences. 


[Oct. 


the  other  three — a  man  sixty-two,  another  sixty-eight,  and  a  woman  twenty-seven 
— had  healthy  lungs. 

(6)  The  size  of  the  trachea  is,  therefore,  shown  to  be  larger  than  the  size  of 
the  two  bronchia  together  in  eleven  subjects,  who  may  be  thus  summarized  :  the 
little  boy  who  died  from  croup,  three  emphysematous  subjects,  four  tuberculous 
(of  whom  one  had  a  pulmonary  emphysema),  one  with  healthy  lungs,  one  man 
with  caseous  pneumonia,  and  a  man  whose  lungs  were  not  examined,  and  in 
whom  the  difference  was  very  small. 

The  conclusions  to  be  derived  from  M.  See's  work  are  the  following:  1.  In  the 
normal  state  the  size  of  the  two  bronchia  are  equal  to  the  size  of  the  trachea ; 
and  it  may  be  added  that,  according  to  a  small  number  of  measurements  which 
he  has  made,  the  size  of  the  bronchial  divisions  is  equal  to  the  size  of  the  bronchia 
from  which  they  arise.  The  respiratory  ducts,  therefore,  represent  a  cylinder 
and  not  a  cone.  2.  In  a  pathological  condition  the  balance  between  the  relative 
size  of  the  trachea  and  of  the  bronchia  is  lost,  so  that  sometimes  the  size  of  the 
bronchia  is  increased,  as  in  chronic  tuberculosis,  and  sometimes  the  trachea  is 
enlarged,  as  in  cases  of  emphysema. — Lancet,  July  13,  1878. 

Supernumerary  Mammae. 

Among  the  congenital  malformations  which  excite  the  surprise  of  those  ignorant 
of  teratological  facts,  and  arouse  the  especial  interest  of  the  evolutionist,  is  the 
occurrence  of  supernumerary  mamma?  and  nipples,  so  that,  instead  of  the  usual 
sufficient  and  even  superfluous  complement,  three  or  even  four  distinct  and  sepa- 
rate structures  are  found.  In  all  ages  they  have  attracted  notice,  and  lately  in 
this  country  Dr.  Sneddon,  and  abroad  M.  B artels  and  Prof.  Leichtexsterx  have 
directed  attention  to  them.  The  Avork  of  the  latter,  which  appears  in  Virchow's 
Archiv,  is  especially  comprehensive,  being  based  on  the  particulars  of  thirteen 
cases  which  have  come  under  his  own  observation,  and  ninety-two  which  he  has 
found  recorded  in  medical  literature.  The  object  for  which  he  has  compared 
them  is  especially  to  ascertain  the  frequency  of  the  occurrence  of  this  anomaly,  its 
most  common  form  and  its  associations — points  on  which  the  statements  in  medi- 
cal literature  vary  much.  This  knowledge  is  essential  if  we  would  obtain  an 
answer  to  the  further  question  of  the  origin  of  the  anomaly,  whether  it  is  to  be 
regarded  as  bizarre  and  accidental,  or  as  the  result  of  some  impeded  or  excessive 
developmental  effort. 

It  is  commonly  asserted  that  extra-rudimentary  breasts  or  nipples  are  occur- 
rences of  considerable  rarity  in  women,  and  of  far  greater  rarity  in  men.  Leich- 
tenstern,  however,  having  been  on  the  lookout  for  the  condition,  is  inclined  to 
attribute  the  supposed  rarity  rather  to  the  absence  of  observation  than  to  the  infre- 
quency  of  the  malformation,  and  his  experience  leads  to  the  conclusion  that  cases 
of  rudimentary  nipples  (polythelia) ,  with  or  without  additional  glands  (polymas- 
tia), occur  pretty  frequently  in  both  sexes,  and  at  least  as  frequently  in  men  as  in 
women.  He  believes  that  the  frequency  should  be  estimated  at  about  one  in  five 
hundred,  and  that  a  very  large  number  of  instances  might  readily  be  collected  if 
those  who  inspect  large  numbers  of  men,  such  as  military  surgeons,  had  their  atten- 
tion directed  to  it.  Many  supernumerary  nipples  are  mistaken  for  naevi  or  spots 
of  molluscum.  In  women  it  has  often  happened  that  the  real  nature  of  such  a 
spot  was  discovered  only  when  pregnancy  caused  it  to  assume  a  functional  activity. 
The  circumstance  that  in  women  attention  is  thus  attracted  to  the  anomaly,  while 
in  men  it  passes  unnoticed,  is  probably  the  reason  why  its  occurrence  has  been 
noted  so  much  more  frequently  in  women  than  in  men  (in  the  proportion  of  seven 
to  two).  The  cases  which  have  come  under  Leichtenstern's  own  notice  corrobo- 
rate this  view,  for  nine  of  them  were  in  men,  and  four  in  women. 


1878.] 


Anatomy  and  Physiology. 


535 


In  the  great  majority  of  cases  (91  percent.)  the  additional  nipples  were  situated 
on  the  anterior  aspect  of  the  thorax.  In  extremely  rare  cases  they  have  been  met 
with  in  the  axilla,  on  the  back,  over  the  acromion,  and  on  the  outer  side  of  the 
thigh.  The  frequency  with  which  they  are  met  with  in  these  irregular  situations 
has  been  much  exaggerated,  and  in  consequence  Darwin  concluded  that  but  little 
weight  could  be  attached  to  them  as  evidence  of  atavism.  When  found  on  the 
anterior  aspect  of  the  thorax,  they  are  placed  in  most  cases  (94  per  cent.)  beneath 
the  normal  mammillae,  between  them  and  the  edge  of  the  ribs.  Sometimes  the 
malformation  is  unilateral,  sometimes  bilateral,  and  in  the  latter  case  the  addi- 
tional organs  are  arranged  symmetrically  or  unsymmetrically.  In  rare  cases,  the 
appendages  occur  above  the  normal  nipples,  and  then,  without  exception,  are 
placed  outside  the  normal  nipple-line.  In  tAvo  cases  only  were  the  extra  nipples 
situated  in  the  middle  line  of  the  body.  When  the  addition  is  unilateral  it  is  much 
more  frequently  on  the  left  than  on  the  right  side,  in  the  proportion  of  seven  to  two. 
Why  this  should  be  is  not  clear,  but  it  is  worth  remembering  that  the  normal 
breast  on  the  left  side  is  more  developed,  on  the  average,  than  that  on  the  right 
side.  This  was  associated  by  Hyrtl  with  the  circumstance  that  the  left  breast  is 
more  used  than  the  right,  on  account  of  the  facility  with  which  a  child  can  be  held 
upon  the  left  arm,  and  the  right  remain  free  ;  but  this  explanation  is  doubted  by 
Leichtenstern  on  the  ground  that  the  preponderance  of  the  left  side  is  to  be  noted 
in  young  persons,  and  because  when  one  breast  is  absent,  or  small,  it  is  almost 
always  the  right  breast  which  thus  suffers.  Klebs  associates  this  lateral  relation 
with  the  rotation  to  the  left  of  the  anterior  segment  of  the  foetus  in  the  amniotic 
investment,  and  points  out  that  congenital  defects  in  the  lung  are  more  frequent 
on  the  left  than  on  the  right  side.  The  congenital  absence  of  one  breast  occurs  in 
cases  of  congenital  defective  formation  of  one-half  of  the  thoracic  wall,  muscular 
or  osseous.  On  the  other  hand,  however,  the  presence  of  supernumerary  mam- 
mas has  never  been  seen  in  conjunction  with  thoracic  defect. 

Very  different  statements  have  been  made  regarding  the  hereditary  transmission 
of  this  anomaly.  In  the  immense  majority  of  cases  certainly  no  such  transmission 
can  be  traced.  Occasionally,  however,  it  appears  indubitable.  In  this  respect  the 
condition  resembles  some  other  congenital  anomalies. 

It  lias  been  said  that  in  the  lower  animals  the  number  of  mammas  diminishes 
according  to  the  developmental  grade  of  the  animal  possessing  them ;  but  this, 
which  has  been  enunciated  as  a  law,  is  of  but  partial  application,  and  does  not 
obtain  when  different  sorts  of  animals  are  compared.  What  is,  however,  of 
perhaps  greater  significance  in  regard  to  the  question  under  consideration  is  that 
in  each  order  considerable  individual  variations  are  observed.  In  the  dog,  for 
instance,  the  number  of  teats  varies,  under  normal  circumstances,  from  seven  to 
ten.  Cuvier  enunciated  the  law,  which  is  no  doubt  accurate,  that  the  greater  the 
variation  in  the  number  of  breasts  in  the  same  species,  the  larger  is  the  number 
normally  possessed.  The  latter  is  commonly  proportioned  to  the  number  of  young 
borne  by  the  animal ;  most  of  those  with  two  breasts — such  as  the  apes,  the  soli- 
peds,  the  Cetacea,  and  the  Edentata — having,  as  a  rule,  only  one  young  at  a  time. 
In  the  same  tribe  as  the  Pachydermata,  species  with  two  breasts — such  as  the  ele- 
phant, hippopotamus,  and  tapir — have  only  one  young  at  a  time;  while  the  sow, 
with  ten  breasts,  bears  from  eight  to  ten  young.  A  popular  idea  has  long  obtained 
in  Germany,  and  has  been  shared  even  by  medical  men,  that  women  with  acces- 
sory breasts  are  disposed  to  twin  conception.  The  polymastia  was  regarded  as  an 
indication  of  a  more  highly  developed  generative  system,  just  as  the  imperfect 
development  of  the  breasts  may  accompany  the  imperfect  development  of  the  ute- 
rus. In  the  last  century  the  question  was  asked,  first  of  Professor  Socin  of  Basle, 
and  then  of  the  Medical  Faculty  in  Tubingen,  whether  a  certain  woman  in  Basle 


536 


Progress  of  the  Medical  Sciences. 


[Oct. 


who  possessed  four  breasts  might  marry  without  incurring  great  risk  of  bearing 
twins.  The  answer  was  that  she  might,  and  the  result  justified  the  conclusion. 
In  the  cases  collected  by  Leichtenstern,  among  seventy  women  with  polymastia 
there  occurred  only  three  twin  conceptions. 

Glandular  structure  commonly  exists,  and  the  additional  breasts  may,  in  very 
rare  instances,  be  employed  for  suckling  a  child.  In  most  cases,  however,  thev 
are  useless  for  this  purpose,  and  frequently,  when  the  infant  is  put  to  one  breast, 
from  the  other  upon  the  same  side  milk  flows.  The  symmetrical  and  regular  situa- 
tion of  the  accessory  mammae  in  the  human  subject  is  very  similar  to  the  position 
of  those  of  animals  which  naturally  possess  more  than  one  pair.  Even  the  axil- 
lary position  has  its  analogies  in  some  animals.  It  is  noticeable,  however,  that 
the  accessory  nipples  often  present  a  very  embryonal  character,  and  possess  still 
the  furrow  by  which  the  development  of  all  nipples  commences.  These  facts  in- 
cline Leichtenstern  to  the  opinion  of  Darwin,  that  the  accessory  breasts  and  nip- 
ples are  really  a  reversion  to  distant  primitive  ancestors,  and  announce  the  exist- 
ence in  man  of  a  latent  developmental  tendency  to  the  production  of  more  than 
two  breasts,  and  these  observations  show  that  such  an  event  occurs  less  rarely 
than  has  been  supposed.  The  irregularity  in  position  of  these  accessory  organs 
might  be  a  difficulty  in  regarding  them  in  the  light  of  a  reversion  to  an  earlier 
type  ;  but  as  Leichtenstern  has  shown,  this  irregularity  is  much  less  than  has  been 
hitherto  supposed. — Lancet,  July  20,  1878. 

Function  of  the  Eustachian  Tube. 

In  a  former  paper  in  Virchow's  Archiv,  vol.  lxx.  p.  447,  Dr.  Hartmaxx  of 
Berlin  related  some  experiments,  which  proved  that  by  Valsalva's  method  of  in- 
flation of  the  tympanic  cavity  a  pressure  of  from  20  to  40  millimetres  of  mercurv 
was  sufficient  to  cause  the  entrance  of  air  into  the  cavity  ;  and  that  during  the  act 
of  swallowing  a  pressure  of  20  millimetres  or  less  is  sufficient. 

He  has  lately  (Archiv  fur  Anatomie  and  Physiologie,  Leipzig,  1877)  had  the 
advantage  of  making  some  experiments  in  the  pneumatic  cabinet  of  the  Jewish 
hospital.  This  cabinet  is  so  arranged  that  any  desired  pressure  within  a  certain 
limit  can  be  made,  and  the  amount  measured  by  means  of  a  conveniently  placed 
quicksilver  manometer.    The  results  of  these  observations  are  as  follows : — 

After  entering  the  cabinet,  if  the  act  of  swallowing  be  avoided,  a  feeling  of 
pressure  is  experienced  on  the  membrana  tympani,  with  a  pressure  of  from  10  to 
40  millimetres,  which  on  the  increase  of  the  pressure  from  40  to  60  millimetre-, 
becomes  painful.  When  this  was  passed,  Dr.  Hartmann  was  compelled,  on  ac- 
count of  the  pain,  to  take  refuge  in  the  act  of  swallowing.  Before  the  swallow- 
ing, the  membrane  is  congested  and  pressed  inwards ;  but,  on  swallowing,  it  i> 
placed  in  a  condition  to  be  able  to  return  to  its  normal  position,  since  the  equi- 
librium between  the  air  of  the  cabinet  and  the  tympanic  cavity  is  again  restored. 
This  at  once  relieves  the  pain. 

From  experiments  made  in  relation  to  the  amount  of  pressure  required  to  cause 
entrance  of  air  into  the  cavity,  he  concludes  that  by  Valsalva's  method  of  infla- 
tion no  actual  position  of  rest  of  the  muscular  structure  of  the  tube  is  reached,  but 
that,  during  the  inflation,  only  a  more  easy  access  is  given  to  the  passage  of  air 
through  the  tube.  The  exit  of  air  from  the  cavity  requires  less  change  of  pressure 
than  for  the  entrance;  and  Dr.  Hartmann  assumes  that  the  tube  acts  as  a  valve, 
which  opens  towards  the  naso-pharyngeal  cavity,  while  by  heightened  pressure  in 
that  cavity  it  remains  closed.  Vocalization  causes,  like  Valsalva's  method, 
changes  which  allow  an  easier  entrance  of  air  into  the  cavity,  but  the  act  of  swal- 
lowing is  the  only  method  of  restoring  the  equilibrium  between  the  tympanic  and 
pharyngeal  cavities. — London  Med.  Record,  June  15,  1878. 


1878.] 


Anatomy  and  Physiology. 


537 


Glycogen. 

Some  interesting  observations  on  the  chemistry  and  physiology  of  glycogen  are 
contributed  to  the  Wiener  Med.  Jahrbuch  by  Dr.  Abeles.  In  order  to  ascer- 
tain the  amount  of  glycogen  in  muscle,  it  is  necessary  to  digest  it  with  caustic 
potash  and  separate  the  albuminous  bodies  by  means  of  a  large  quantity  of  a  solu- 
tion of  iodide  of  potassium  and  mercury.  Abeles  proposes  to  separate  them, 
instead,  by  chloride  of  zinc,  the  solution  having  previouly  been  rendered  almost 
neutral  by  hydrochloric  acid.  If  it  be  boiled  for  from  twenty  to  thirty  minutes 
with  the  zinc,  the  albumen  is  precipitated  in  a  dense  mass,  and  the  solution  is 
readily  filtered.  The  glycogen  may  then  be  precipitated  by  alcohol.  No  forma- 
tion of  sugar  from  the  glycogen  occurs  during  the  boiling  with  chloride  of  zinc. 

Glycogen  can  also  be  precipitated,  it  is  found,  by  baryta.  If  a  saturated 
solution  of  baryta  be  added  to  a  solution  of  glycogen,  an  abundant  white  precipi- 
tate is  formed,  which  sinks  to  the  bottom  of  the  vessel  on  standing.  When  col- 
lected and  dried  in  vacuo  at  a  temperature  of  212°  F.,  it  was  found  to  have  the 
following  composition :  C18H30O16Ba.  The  same  precipitate  occurred  when 
baryta- water  was  added  to  a  liver  decoction,  and  from  it  the  glycogen  could  be 
liberated  by  dilute  sulphuric  acid ;  but  this  method  is  found  to  be  not  very  con- 
venient, because  the  barytic  sulphate  separates  from  the  solution  of  glycogen 
slowly  and  with  difficulty. 

It  is  well  known  that  curara  produces  glycosuria,  but  the  mechanism  of  the 
production  of  the  sugar  is  a  point  which  has  been  much  discussed  and  is  still 
uncertain.  Bernard  thought  that  it  was  by  the  influence  of  the  poison  on  the 
nerves  of  the  liver.  Abeles  has  found  that  the  sugar  in  the  blood  of  a  dog  which 
had  fasted  for  five  days  was  .046  per  cent.,  and  that  an  hour  after  poisoning  with 
curara  it  had  risen  to  .13  per  cent.  He  believed  that  so  considerable  an  increase 
in  the  amount  of  sugar  in  the  blood  could  not  possibly  arise  from  a  transformation 
of  the  glycogen  which  remained  in  the  liver  after  five  days'  fasting.  He  accord- 
ingly investigated  the  amount  of  glycogen  in  the  muscles  before  and  after 
poisoning  by  curara.  The  animal  having  been  narcotized,  a  piece  of  muscle  was 
excised  from  one  leg ;  curara  was  injected,  artificial  respiration  maintained  for 
(in  different  cases)  from  twenty-five  minutes  to  an  hour  and  three-quarters,  and 
then  a  similar  piece  of  muscle  removed  from  the  other  leg.  In  all  cases  the 
amount  of  glycogen  in  the  muscle  after  the  curara  was  larger  than  before  the 
injection ;  the  anticipated  diminution  in  the  glycogen  could  not  in  any  case  be 
found.  The  experiments  thus  appear  to  support  Bernard.  They  show,  at  any 
rate,  that  the  sugar  which  passes  into  the  blood  is  not  derived  from  the  glycogen 
of  muscle. 

Glycogen,  in  large  quantities,  appears  to  be  an  active  blood-poison.  Bohm 
and  Hoffmann  have  injected  it  into  the  jugular  vein  of  cats,  and  found  that  after 
the  injection  of  from  three  to  ten  grammes,  the  urine  contained  haematin.  Hence 
it  appears  that  glycogen  is  one  of  those  substances  which  can  dissolve  the  blood- 
corpuscles.  The  urine  contained  albumen,  and,  when  this  was  separated,  rotated 
polarized  light  to  the  right,  and  reduced  oxide  of  copper,  but  the  reduction  was 
far  less  than  corresponded  to  the  amount  of  action  on  polarized  light.  This 
dextro-rotatory  substance  could  be  separated  by  the  addition  of  six  or  eight  vol- 
umes of  alcohol,  and  it  was  then  found  to  be  soluble  in  water  without  opalescence, 
to  give  no  colour  with  iodine,  to  have  no  power  of  reducing  Fehling's  solution, 
but  to  be  transformed  into  grape  sugar  by  sufficient  boiling  with  acids.  The 
average  rotating  power  on  light  was  found  to  be  194.3°,  a  lower  power  than  gly- 
cogen, which  was  determined,  on  an  average  of  seven  observations,  to  be  226.7°. 
Hence  the  substance  corresponds  to  the  achroodextrin  of  Briicke,—  Lancet,  July 
13,  1878. 


538 


Progress  of  the  Medical  Sciences. 


[Oct. 


MATERIA  MEDIC  A  AND  THERAPEUTIC  S. 

The  Physiological  Action  of  Purgatives. 
This  subject  has  recently  been  reinvestigated  by  L.  Brieger  (Archiv  fiir  Exp. 
Pathologie,  viii.),  on  the  basis  of  Moreau  and  Brunton's  experiments.  Large 
dogs,  which  had  been  kept  a  day  or  two  without  food,  were  used.  They  were 
chloroformed,  and  then  a  loop  of  small  intestine  was  ligatured  in  two  places,  and 
thoroughly  washed  out  with  warm  water  through  small  openings  made  just  to  the 
inner  side  of  the  ligatured  points.  These  openings  were  then  carefully  closed 
with  sutures,  and  the  isolated  loop  of  gut  was  divided  into  three  parts,  each  from 
twenty  to  twenty-five  centimetres  long.  The  experimental  purgatives  were  then 
slowly  introduced  into  the  two  outside  compartments,  the  central  one  being  left 
for  comparison.  The  animals  were  generally  killed,  and  the  parts  examined, 
about  four  hours  and  a  half  after  the  injection,  but  sometimes  later.  Dilute  solu- 
tions of  saline  aperients  (sulphate  of  magnesia,  common  salt)  were  absorbed  with- 
out causing  any  change  in  the  bowel ;  but  as  the  strength  of  the  solution  was  in- 
creased, the  ligatured  bowel  contained  more  and  more  clear  yellow  alkaline  liquid, 
containing  flakes  of  mucus,  intestinal  epithelium,  and  mucous  corpuscles.  Drastic 
drugs  (croton  oil,  colocynth)  caused  the  secretion  of  a  bloody  liquid,  or  even  set 
up  diphtheritic  inflammation  of  the  mucous  membrane,  while  laxatives  such  as 
senna,  rhubarb,  aloes,  gamboge,  and  castor  oil  invariably  caused  firm  contraction 
of  the  muscular  coats,  the  injected  drug,  its  watery  parts  being  absorbed,  being 
found  spread  over  the  whole  mucous  membrane,  which  was  not  inflamed.  The 
result  was  the  same  if  the  animals  were  killed  as  late  as  sixteen  hours  after  the 
injection.  It  thus  appears  that  laxatives  mainly  act  by  exciting  peristaltic  con- 
traction of  the  intestine ;  whereas  salines,  as  was  previously  known,  attract  water 
into  the  bowel,  and  also  induce  abundant  secretion  from  the  intestinal  glands. 
On  the  other  hand,  drastics  in  small  doses  have  a  similar  action  to  laxatives,  but 
in  large  ones  they  cause  inflammatory  exudation  and  hypersecretion.  Brieger' s 
results,  therefore,  differ  from  those  of  Moreau  and  Brunton  in  the  role  he  assigns 
to  the  laxatives.  If  we.  remember  rightly,  the  latter  observers  found  that  the 
various  purgatives  used  agreed  in  producing  a  copious  transudation  of  watery  fluid 
into  the  bowel,  and  this  Brieger  only  admits  in  the  case  of  the  saline  and  drastic 
aperients. — Med.  Times  and  Gaz.,  Aug.  3,  1878. 

Subnitrate  of  Bismuth. 

Prof.  Gubler  (Bull,  de  V  Academie,  July  16),  speaking  of  this  substance  at 
the  Acadeniie,  observed  that  it  is  a  mechanical  absorbent  just  like  any  other  dry 
powder ;  and  it  is  a  certain  antacid,  for  while  it  does  not  absorb  carbonic  acid  gas. 
which  is  secondary,  it  efficiently  absorbs  the  normal  acids  in  excess  in  the  gastric 
juice,  and  especially  the  acids  formed  accidentally  at  the  expense  of  alimentary 
or  other  matters  introduced  into  the  primce  vice — acetic  and  lactic  and  volatile 
fatty  acids.  Moreover,  the  basic  salt  of  bismuth  possesses  the  very  great  disad- 
vantage of  absorbing  sulphuretted  hydrogen  gas,  or  of  producing  with  the  sulpho- 
hydrate  of  ammonia,  by  double  decomposition,  nitrate  of  ammonia,  and  sulphuret 
of  bismuth.  In  this  latter  effect  bismuth  can  only  be  replaced  with  difficulty, 
chalk,  in  particular,  the  employment  of  which  would  be  so  convenient,  so  cheap, 
and  so  inoffensive,  not  seizing  hold  of  sulphuretted  hydrogen.  Oxide  of  zinc  is 
the  only  other  substance  that  can  fulfil  all  the  indications  so  well  met  by  bismuth, 
and  it  easily  becomes  nauseating  or  emetic.  It  is,  however,  a  remarkable  thing 
that  this  inconvenience  especially  occurs  when  small  doses  of  the  oxide  are  em- 


1878.] 


Materia  Medica  and  Therapeutics. 


539 


ployed — as  from  a  twentieth  to  a  fifth  of  a  gramme — which  always  meet  with 
enough  acid  in  the  stomach  to  convert  them  into  neutral  salts.  When  large  doses 
are  given — as  a  half  to  one.  two,  three,  and  four  grammes  per  diem — they  are 
exempt  from  all  emetic  properties,  and  especially  when  united  with  sufficient 
bicarbonate  of  soda  to  neutralize  the  acids  of  the  primce  vice.  This  combination 
furnishes  excellent  results  in  the  same  cases  in  which  bismuth  succeeds.  The 
oxide  of  zinc,  indeed,  has  this  advantage  over  bismuth :  that  its  sulphuret  is 
white,  and  thus  does  not  mask  the  presence  of  blood  in  the  stools ;  nor  does  it 
raise  fears  in  the  mind  of  the  timid  of  the  presence  of  mehena. — Med.  limes  and 
Gaz.,  Aug.  3,  1878. 

Oil  of  Rosemary. 

Professor  Kohler  and  Herr  Schreiber,  of  Halle,  have  published  in  Xo.  23, 
Centralblatt  Med.  Wiss.j  the  results  of  some  experiments  on  tho  physiological 
action  of  oil  of  rosemary,  which  may  turn  out  to  be  of  great  therapeutic  value. 
The  chief  action  of  the  oil  is  on  the  cerebro-spinal  nerve-centres.  The  blood- 
pressure  falls,  owing  to  paralysis  of  the  vaso-motor  centre  in  the  medulla,  but  the 
heart  is  unaffected,  and  there  is  only  retardation  of  the  pulse  if  the  drug  is  pushed 
to  its  utmost  extent :  in  the  latter  case  the  respiratory  centre  becomes  ultimately 
paralyzed.  Reflex  excitability  is  increased  by  small  and  diminished  by  large 
doses  of  the  oil,  or  by  the  repeated  injection  of  small  ones.  Large  doses  antago- 
nize the  pathological  irritability  induced  by  strychnia.  The  most  important  effect 
of  the  oil,  however,  is  on  the  temperature,  though  for  this  purpose  it  must  be 
inhaled  in  the  form  of  vapour,  and  not  given  by  the  stomach.  By  the  latter  form 
of  administration  only  a  temporary  reduction  of  about  2°  centigrade  can  be  ob- 
tained ;  whereas  by  inhalation  the  temperature  may  be  reduced  without  difficulty 
as  much  as  8°.  If  the  same  effect  can  be  produced  on  the  febrile  human  subject 
without  the  development  of  other  poisonous  symptoms,  the  inhalation  of  oil  of 
rosemary  may  prove  to  be  a  useful  addition  to  our  antipyretic  remedies,  and  we 
hope  to  hear  before  long  that  the  experiment  has  been  tried  and  succeeded. 
Kohler  and  Schreiber  did  not  find  the  abortive  action  which  has  been  ascribed  to 
the  oil  confirmed  in  experiments  on  rabbits.  Its  stimulant  effects  excite  peristal- 
tic action  of  the  bowels,  and  produce  slight  diarrhoea.  The  oil  appears  to  be 
diuretic  if  given  by  the  stomach  or  by  inhalation,  and  the  urine  passed  by  both 
animals  and  men  under  these  circumstances  smells  distinctly  of  violets.  Its  pro- 
longed administration  per  orem  for  many  weeks  may  produce  a  slight  degree  of 
fatty  change  in  the  liver,  and  nephritis,  with  albumen  and  casts  in  the  urine. 
The  irritability  of  the  muscles  is  never  affected  by  poisoning  with  oil  of  rosemary, 
nor  has  any  alteration  in  the  size  of  the  pupils  been  observed. — Med.  Times  and 
Gaz.,  Aug.  3,  1878. 

Comparison  of  Opium,  Belladonna,  and  Aconite. 
M.  Jules  Simox  establishes  the  following  comparison  between  opium,  bella- 
donna, and  aconite :  1 .  In  regard  to  their  action  on  the  alimentary  canal,  opium 
causes  thirst,  dryness  without  acrimony,  want  of  appetite,  nausea,  vomiting,  con- 
stipation ;  belladonna,  thirst,  dryness  with  acrimony,  nausea,  vomiting,  and  diar- 
rhoea :  aconite,  dryness,  sensations  of  pricking  and  burning  of  the  tongue,  saliva- 
tion in  full  doses,  vomiting,  and  diarrhoea.  2.  In  regard  to  their  action  on  the 
circulation,  opium  acts  as  a  stimulant,  causes  diminution  of  pressure,  though  it  is 
sometimes  without  action,  and  in  large  doses  causes  acceleration  of  the  pulse  and 
collapse.  Belladonna  acts  as  a  sedative,  lowers  the  strength,  retards  the  fre- 
quency of  the  pulse,  and  produces  a  febrile  state  of  the  system.  Aconite  acts  as 
a  sedative,  diminishes  the  arterial  tension,  renders  the  face  pallid,  retards  the  fre- 


540 


Progress  of  the  Medical  Sciences. 


[Oct. 


quency  of  the  pulse,  and  stops  the  heart  in  diastole.  3.  In  regard  to  the  respira- 
tion, opium  allays  dyspnoea,  when  present,  by  diminishing  the  bronchial  secre  - 
tion ;  in  large  doses  it  causes  collapse.  Belladonna  calms  down  excited  respira- 
tion, diminishes  secretion,  and  in  large  doses  renders  respiration  spasmodic  and 
irregular.  Aconite  retards  respiration  by  its  direct  action  on  the  nerves.  4.  In 
regard  to  their  action  in  febrile  states,  opium  augments  the  cutaneous  secretions, 
and  produces  general  malaise,  erythema,  and  eruptions.  Belladonna  produce- 
neither  sweating  nor  general  discomfort,  raises  the  temperature,  and  sometimes 
causes  sclarlatina-like  eruptions.  Aconite  lowers  the  temperature.  5.  In  regard 
to  their  actions  on  the  secretions,  opium  diminishes  the  quantity  of  urine,  and  in 
fact  diminishes  the  secretions  generally.  Belladonna  causes  augmentation  of  the 
renal  secretion,  with  diminution  of  the  bronchial  secretion.  Aconite  causes 
increase  of  the  urinary  secretion,  but  diminishes  the  bronchial  secretion.  6.  In 
regard  to  their  action  on  the  nervous  system,  opium  acts  chiefly  on  the  cerebro- 
spinal system,  belladonna  on  the  cerebro-spinal  system,  and  aconite  on  the  spinal 
cord.  Opium  causes  somnolence,  sleep,  intoxication,  vertigo,  muscular  debility, 
diminution  of  common  sensibility,  contraction  of  the  pupil,  diminution  of  the 
activity  and  vigour  of  reflex  actions.  Belladonna  causes  sleeplessness,  gay  or 
furious  delirium,  hallucinations,  muscular  agitation,  diminution  of  the  sensibility 
of  the  face,  dilated  pupils,  and  remarkable  diminution  of  the  reflex  acts.  Aconite 
leaves  the  intellectual  faculties  intact,  but  causes  muscular  torpor,  anaesthesia, 
hallucination  of  the  senses,  diminution  of  reflex  actions,  and  produces  slight  dila- 
tation of  the  pupil. — Lancet,  July  20,  1878. 

Butyl  Chloral. 

According  to  Prof.  Liebreich  {Lancet,  July  20,  1878),  in  the  human  subject, 
as  well  as  in  the  lower  animals,  the  first  action  of  the  drug  is  to  produce  anaesthe- 
sia, which  begins  in  the  head  and  gradually  passes  to  the  rest  of  the  body,  reflex 
irritability  remaining  intact  in  the  limbs  for  some  time  after  it  has  been  abolished 
in  the  head.  Then  follows  narcosis  ;  but  it  is  important  to  observe  that  anaesthesia 
in  the  head  and  face  may  be  complete  before  any  trace  of  narcosis  manifests  itself. 
From  a  consideration  of  this  fact  Professor  Liebreich  suggests  the  use  of  butyl 
chloral  in  operations  on  the  face,  in  cases  where  other  anaesthetics  are  contra-indi- 
cated.   The  dose  for  this  purpose  is  from  one  to  two  grammes  (15  to  30  grains). 

In  some  remarks  on  the  action  of  butyl  chloral  on  the  heart  and  the  manner  of 
death  in  fatal  cases,  Prof.  Liebreich  points  out,  that,  whereas  in  the  case  of  chlo- 
ral hydrate  the  heart  was  paralyzed  and  its  action  ceased  before  the  movements  of 
respiration  came  to  an  end,  the  reverse  held  good  in  the  case  of  butyl  chloral.  A 
fatal  dose  of  that  substance  atticks  the  respiratory  centre  in  the  medulla  oblon- 
gata and  paralyzes  it,  while  the  heart  is  unaffected  and  continues  to  pulsate  for 
some  time  after  death. 

To  demonstrate  this  fact  Professor  Liebreich  showed  two  rabbits,  both  of  which 
were  in  a  state  of  complete  narcosis,  the  one  from  the  effects  of  chloral  hydrate, 
the  other  from  butyl  chloral.  In  the  case  of  the  first  animal  the  thorax  was 
opened  just  as  all  respiratory  movements  ceased.  The  heart  was  lying  motionless, 
both  ventricles  being  dilated  and  filled  with  blood.  Artificial  respiration  had  no 
effect  in  reproducing  the  cardiac  contractions.  But,  on  the  other  hand,  when  the 
thoracic  cavity  of  the  rabbit  poisoned  with  butyl  chloral  was  opened  (at  exactly 
the  same  stage)  the  heart  was  found  to  be  beating  regularly,  and  to  all  appear- 
ance normally.  After  about  two  minutes  the  beats,  which  during  that  period  had 
become  slow,  ceased.  Artificial  respiration  at  once  restored  the  pulsations,  and 
so  long  as  the  rhythmical  inflation  of  the  lungs  was  kept  up,  the  contraction  of 


1878.] 


Materia  Medica  and  Therapeutics. 


541 


the  heart  continued ;  thus  affording  an  admirable  illustration  of  the  views  as  to 
the  action  of  the  drug  which  had  been  enunciated  in  the  course  of  the  lecture. 
Professor  Liebreich  also  indicated  that  this  property  gave  the  drug  considerable 
advantage  as  an  anaesthetic  for  vivisectional  purposes,  especially  in  England. 

Prof.  Liebreich  refers  to  the  value  of  butyl  chloral  in  cases  of  tic  douloureux, 
and  advises  its  administration,  dissolved  in  glycerine  and  water,  rather  than  in  alco- 
hol, in  doses  of  from  one  to  two  grammes. 

Misuse  of  Bromide  of  Potassium. 

According  to  Boettger  (Allgcmeine  Zeitsclirift  fur  Psychiatric,  Bandxxxv., 
Heft  3),  it  is  by  no  means  uncommon  for  methods  of  treatment  of  the  greatest 
importance,  so  soon  as  they  become  well  known  to  the  laity  as  well  as  to  the  pro- 
fession, to  be  so  misapplied  as  to  cause  unfavourable  results,  and  thus  to  bring 
general  discredit  upon  procedures  which,  when  adopted  with  discrimination,  are 
of  the  highest  value.  As  instances  of  this  may  be  cited,  the  administration  of 
chloroform  and  of  hypodermic  injections,  especially  of  morphia;  also  the  use  of 
chloral  hydrate ;  from  the  abuse  of  all  of  which  the  most  lamentable  effects  are 
frequently  brought  under  our  notice. 

Among  the  class  of  nervine  and  hypnotic  medicines,  bromide  of  potassium  has 
of  late  taken  very  high  rank ;  administered  timidly  at  first  in  small  doses,  it  is 
now  freely  given  in  large  quantities,  its  use  as  a  hypnotic  is  constantly  becoming 
more  frequent,  it  has  taken  an  important  place  in  the  materia  medica  of  alienists, 
it  has  been  recommended  as  a  sovereign  remedy  for  epilepsy,  and  the  literature 
of  the  subject  is  already  very  considerable.  All  these  circumstances  render  the 
drug  peculiarly  liable  to  abuse.  For  a  long  time  it  was  regarded  as  incapable 
of  doing  harm,  until  Seguin  showed  that  its  indiscriminate  use  was  greatly 
to  be  deprecated,  and  that  the  long-continued  administration  of  preparations 
of  bromine  may,  and  often  does,  give  rise  to  a  well-defined  disease  (broinism), 
characterized  by  the  following  symptoms :  feelings  of  weakness  and  lassitude, 
depression  of  the  heart's  action,  coldness  of  the  extremities,  a  peculiar  heavi- 
ness of  speech,  a  pustular  or  papular  eruption  of  the  skin  (which  may  be  con- 
fined to  a  few  spots,  or  may  be  so  abundant  as  to  resemble  that  of  variola), 
and,  lastly,  a  peculiar,  sweet,  but  unpleasant  odour  of  the  breath,  which  Dr. 
Boettger  has  invariably  been  able  to  distinguish  in  patients  who  have  taken  the 
drug  continuously . 

In  still  higher  degrees  of  bromism,  with  which  the  present  paper  is  more 
directly  concerned,  Seguin  found  that  stupor  supervened,  memory  and  articula- 
tion seemed  to  be  especially  affected,  hallucinations  of  all  the  senses  were  ob- 
served, tremor  of  the  muscles  came  on  with  unsteady  gait,  all  movements  became 
uncertain,  and  the  more  delicate  ones  impossible,  the  pupils  were  unequal  and 
reacted  only  slowly ;  in  male  patients  sexual  power,  and  in  females  menstruation, 
was  disturbed.  It  is  evident  that  a  patient  in  this  advanced  stage  of  bromism 
might  easily  be  taken  to  be  suffering  from  paralytic  dementia.  Seguin  admits 
that  the  diagnosis  might  present  great  difficulty,  and  Boettger  has  actually  expe- 
rienced it ;  the  history  of  the  case  is  the  most  important  point  from  which  to 
form  an  opinion.  A  fatal  issue  is,  moreover,  not  uncommon  in  severe  cases  of 
bromism.  The  following  case  illustrates  well  the  resemblance  between  advanced 
bromism  and  the  last  stage  of  general  paralysis. 

Herr  C.  R.,  aged  29,  well-educated,  had  no  hereditary  predisposition  to  in- 
sanity, and  had  previously  enjoyed  good  health.  With  the  exception  of  some 
severe  hardships  which  he  suffered  while  serving  in  the  Franco-German  war,  he 
had  always  led  a  steady  and  regular  life.    After  not  having  felt  quite  himself  for 


542 


Progress  of  the  Medical  Sciences. 


[Oct. 


some  time,  and  suffering  from  want  of  mental  activity,  etc.,  in  June,  1877,  marked 
depression  set  in,  accompanied  by  delusions  of  persecution  and  hallucinations  of 
various  senses.  Continuous  sleeplessness  being  also  present,  his  medical  attend- 
ant prescribed  bromide  of  potassium  in  doses  from  80  to  90  grains  per  diem. 
The  patient,  however,  took  the  drug  irregularly ;  on  some  days  he  only  took  45 
grains,  but  on  others  as  much  as  150  and  180  grains;  within  four  months  he  con- 
sumed about  35  ounces  of  the  drug,  giving  an  average  of  over  130  grains  daily. 
During  this  time  his  condition  became  rapidly  worse,  he  became  stupid  and  for- 
getful, his  features  lost  their  expression,  and  his  bearing  was  careless  and  unsteady. 
His  speech  was  heavy,  though  not  exactly  stammering,  muscular  tremor  super- 
vened, and  the  patient's  gait  became  staggering.  In  this  condition,  he  was  brought 
to  Dr.  Boettger  at  the  Carlsfeld  Asylum  as  a  case  of  general  progressive  paralysis. 
The  first  impression  made  by  the  patient  seemed  to  justify  this  diagnosis.  Besides 
the  symptoms  mentioned  above,  it  was  noted  that,  the  pupils  were  very  unequal 
(the  left  being  the  smaller),  and  botli  reacted  very  slowly  ;  the  tongue  was  slightly 
coated,  tremor  of  its  muscular  bundles  was  observed,  and  it  was  inclined  to  the 
left  side  ;  speech  was  slow,  heavy,  and  interrupted  by  long  pauses,  as  if  the  patient 
had  a  difficulty  in  thinking  of  his  words.  The  pulse  was  small  and  faint,  the  sur- 
face-temperature low ;  his  whole  appearance  indicated  mental  and  physical  decay. 
The  entire  body  inclined  markedly  towards  the  left  side,  as  is  frequently  the  case 
in  paralytic  patients.  The  peculiar  faint  sweet  smell  of  the  breath,  already  noticed 
as  occurring  in  bromism,  was  very  marked.  The  first  diagnosis  made  was  that  of 
paralytic  dementia. 

At  first,  small  doses  of  the  bromide  were  given,  and  the  patient  rapidly  became 
more  stupid  and  unsteady  in  his  gait;  he  once  fell  while  walking  and  injured  his 
forehead,  when  it  was  noted  that  sensibility  to  pain  was  greatly  diminished.  After 
a  very  few  days,  owing  to  loss  of  appetite  and  strong  fetor  of  the  breath,  the  bro- 
mide of  potassium  was  discontinued,  quinine  and  iron  being  prescribed  instead; 
the  immediate  impi-ovemcnt  in  the  patient's  condition,  combined  with  other  con- 
siderations, very  soon  made  it  clear  that  the  case  was  one  of  bromism.  The 
patient  had  to  be  fed  with  a  spoon,  and  took  only  liquid  and  soft  food  for  some 
time  ;  the  stupidity  continued  for  about  a  month;  after  that  time  Herr  R.  became 
gradually  more  active  ;  his  bearing  was  more  upright,  and  his  countenance  showed 
more  expression ;  his  gait  also  became  more  sure,  and  the  fetor  of  his  breath  dis- 
appeared. Appetite  and  interest  in  things  in  general  returned.  Memory  also 
improved,  but  was  quite  extinguished  for  events  which  had  occurred  during  the 
height  of  the  bromism.  During  the  next  few  months  the  patient  rapidly  recov- 
ered, all  the  paretic  symptoms  passed  away,  and  he  is  now  enjoying  good  mental 
and  bodily  health. — London  Medical  Record,  Aug.  15,  1878. 

Therapeutic  Action  of  Iodoform. 
Dr.  Moleschott  (Wiener  Medicin.  Wochenschrift,  Nos.  24,  25,  and  26, 
1878)  states  that  he  has  used  iodoform  with  good  result  in  the  treatment  of  exu- 
dation into  the  pleura,  pericardium,  and  peritoneum,  and  of  the  acute  hydroce- 
phalus of  children.  He  generally  applied  it  in  the  form  of  ointment  (1  in  15  of 
lard)  or  with  elastic  collodion  (1  in  15  of  collodion).  Large  glandular  swellings 
were  caused  to  disappear  under  the  use  of  the  iodized  collodion.  It  was  found 
useful  as  a  means  of  assuaging  pain  in  gout,  neuralgia,  and  neuritis.  Syphilitic 
myocarditis  was  cured  by  iodoform  inunction,  combined  with  the  internal  use  of 
the  drug  in  doses  of  from  three-fourths  of  a  grain  to  a  grain  and  a  half  daily. 
Iodoform  appears  to  act  like  digitalis  on  the  heart,  increasing  the  strength  and 
reducing  the  frequency  of  its  beats ;  and  was  hence  used  successfully  in  uncom- 
pensated valve-disease.    Its  action  depends  probably  on  its  ready  decomposition. 


1878.] 


Materia  Medica  and  Therapeutics. 


543 


by  which  the  iodine  in  a  nascent  state  is  brought  into  action  on  the  tissues. — 
London  Med.  Record,  Aug.  15,  1878. 

Action  of  Pilocarpin. 

Dr.  A.  Loesch  (Deutches  Archiv.  fur  Klin.  Med.,  Band  xxi.,  Heft  2  and  3) 
found  that  the  subcutaneous  injection  of  2  centigrammes  (0.3  grain)  of  muriate  of 
pilocarpin  in  dropsical  and  non-dropsical  cases  was  followed  in  a  period  varying 
from  two  to  five  minutes  by  diaphoresis  and  salivation,  varying  in  intensity,  but 
generally  lasting  an  hour  and  a  half  or  two  hours.  The  loss  of  weight  was  as  a 
rule  from  700  to  900  grammes  ;  in  some  cases  it  was  twice  as  much,  in  others  much 
less.  The  internal  administration  of  4  centigrammes  (0.6  grain)  was  followed  at 
the  end  of  23  minutes  by  an  increased  secretion  which  lasted  only  15  minutes. 
Severe  vomiting  was  sometimes  observed  ;  this  unpleasant  symptom  also  follows 
the  use  of  jaborandi.  Dr.  Loesch  warns  against  the  use  of  pilocarpin  in  cardiac 
affections,  as  its  effect  on  the  heart's  action  was  always  considerable.  This  was  in 
some  cases  increased,  and  sometimes  was  rendered  irregular. 

Fr'ankel  {Cliariti-Annalen,  1878)  gives  an  account  of  experiments  on  dogs  per- 
formed by  him  in  conjunction  with  Leyden,  from  which  the  conclusion  is  drawn 
that  a  deleterious  action  on  the  heart  is  not  to  be  expected  from  the  use  of  the 
drug.  Doses  up  to  0.6  grain  had  but  little  effect  on  the  frequency  of  the  pulse 
and  the  arterial  pressure,  as  measured  by  the  kymograph.  When  the  amount 
injected  was  increased,  the  frequency  of  the  pulse  was  remarkably  reduced,  even 
when  both  vagi  were  divided ;  but,  when  once  a  certain  limit  had  been  reached, 
there  was  no  further  reduction  of  frequency  even  under  increased  doses,  provided 
that  artificial  respiration  were  practised.  The  injection  of  small  quantities  of 
atropia  at  once  interrupted  the  action  of  the  pilocarpin.  These  drugs  thus  seem 
to  be  antagonistic  in  their  action  on  the  secretion  of  sweat. 

Dr.  Fr'ankel  relates  some  cases  in  which  the  use  of  pilocarpin  was  followed  by 
beneficial  results.  In  a  case  of  acute  nephritis,  25  milligrammes  (three-eighths  of 
a  grain)  of  pilocarpin  were  injected  every  day  for  seven  days  in  succession,  then 
every  second  or  third  day  ;  the  result  was  removal  of  the  oedema,  and  restoration  of 
the  normal  secretion  of  urine.  In  two  analogous  cases,  recovery  followed  injec- 
tions made  on  alternate  days  for  3j  weeks  and  14  days  respectively.  A  fourth 
case  was  one  of  bronchial  catarrh  with  severe  cyanosis,  oedema,  ascites,  dyspnoea, 
and  scanty  secretion  of  urine.  Expectant  treatment  and  digitalis  were  useless ; 
treatment  by  pilocarpin  was  at  once  followed  by  improvement  and  ultimately  by 
cure. — Lond.  Med.  Record,  Aug.  15,  1878. 

Action  of  Muriate  of  Pilocarpin  in  Children. 

Dr.  Demme,  of  Bern  (Centralzeitung  fur  Kinder heilkunde) ,  has  administered 
muriate  of  pilocarpin  by  subcutaneous  injection  to  33  children.  Of  these,  18 
suffered  from  desquamative  nephritis  with  dropsy  after  scarlatina ;  3  from  nephri- 
tis after  diphtheria  (without  scarlatina)  and  a  high  degree  of  dropsy.  In  12 
cases,  the  diseases  were  dropsy  from  disease  of  the  valves  of  the  heart,  multi- 
articular rheumatism,  whooping-cough,  broncho-pneumonia,  and  parotitis.  The 
ages  of  the  children  varied  from  9  months  to  twelve  years..  The  dose  adminis- 
tered subcutaneously  was — up  to  the  end  of  the  second  year,  5  milligrammes  (-075 
grain)  ;  from  the  second  to  the  sixth  year,  7.5  milligrammes  to  1  centigramme 
(0.11  to  0.15  grain)  ;  and  from  the  seventh  to  the  twelfth  year,  1  centigramme 
to  a  quarter  of  a  gramme. 

The  injections  were  well  borne,  except  in  two  cases ;  in  one  of  these,  vomiting, 
hiccup,  pallor  of  the  face,  and  syncope ;  in  the  other,  yawning,  hiccup,  and 


544 


Progress  of  the  Medical  Sciences. 


[Oct. 


twitchings  of  the  limbs,  appeared  from  three  to  five  minutes  after  the  injection. 
The  proper  action  of  the  pilocarpin  was  imperfect  in  both  these  cases. 

Pilocarpin  was  found  to  be  an  excellent  diaphoretic  and  sialagogue.  The  latter 
action  was  more  marked  in  very  young  children,  the  former  in  older  ones.  The 
action  usually  commenced  from  three  to  seven  minutes  after  the  administration, 
increased  up  to  15  minutes,  remained  at  its  height  up  to  20  or  40 — and  in  rare 
cases  75 — minutes,  and  then  gradually  ceased.  There  was  an  inconsiderable  fall 
of  temperature.  The  frequency  of  the  pulse  was  increased  by  20  to  60  beats;  the 
pulse- wave  was  fuller.  The  amount  of  urine  was  only  exceptionally  increased ; 
in  two  cases  there  were  watery  stools.  Dr.  Demme  arrives  at  the  following  con- 
clusions : — 

1.  Pilocarpin  is  an  effective  diaphoretic  and  sialagogue  in  childhood. 

2.  It  is  borne  very  well,  in  appropriate  doses,  even  by  children  of  very  tender 

years. 

3.  Unfavourable  after-symptoms  are  but  rarely  observed,  and,  probably,  may 
be  altogether  prevented  by  the  administration  of  small  doses  of  brandy  before  the 
injection. 

4.  The  conditions  in  which  it  is  chiefly  indicated  are  the  parenchymatous  in- 
flammations of  the  kidney  with  dropsy,  following  scarlatina. 

5.  Pilocarpin  does  not  appear  to  exercise  an  influence  on  the  heart's  action. — 

London  Med.  Record,  Aug.  15,  1878. 

Action  of  Pilocarpin  and  Cotoin. 

Dr.  Cloetta  read  a  paper  on  this  subject  to  the  Medical  Society  of  the  Can- 
ton of  Zurich  (Correspondez-Blatt  fur  Schweizer  Aertze,  Band  vii.).  In  healthy 
horses,  the  subcutaneous  injection  of  half  a  gramme  of  Merk's  muriate  of  pilocar- 
pin was  followed  in  three  minutes  by  an  increased  flow  of  saliva;  in  eight  min- 
utes, the  pulse  rose  from  40  to  60;  in  ten  minutes,  sweating  followed,  first  at  the 
place  of  injection,  and  thence  spread  towards  the  head  and  over  the  whole  body. 
The  temperature  in  the  rectum  remained  equal ;  that  of  the  skin  fell  considerably. 
The  loss  of  weight  (excluding  feces  and  urine)  amounted  in  an  hour  and  three- 
quarters  to  more  than  22  pounds — more  than  2  per  cent. 

In  man,  similar  phenomena  were  produced  by  the  subcutaneous  injection  of  one 
or  two  centigrammes  (0.15  to  0.3  grain)  ;  salivation,  feeling  of  heat  in  the  head, 
redness  of  the  face,  throbbing  of  the  carotids,  and  sweating  on  the  head  and  then 
on  the  rest  of  the  body.  The  pulse  increased  from  20  to  40  in  the  minute;  the 
breathing  was  quickened.  The  use  of  two  centigrammes  was  generally  followed 
by  nausea.  The  action  of  the  drug  lasted  one  or  two  hours ;  the  temperature  in 
the  rectum  was  unchanged ;  that  in  the  axilla  fell  sometimes  as  much  as  3  or  4 
(leg.  Pahr.    No  diuretic  action  was  observed. 

The  results  of  Dr.  Cloetta' s  experiments  have  led  him  to  question  whether 
pilocarpin  has  much  therapeutic  value.  Neither  in  dropsy  following  heart-disease 
or  chronic  nephritis,  nor  in  pleuritic  exudations,  was  the  use  of  pilocarpin  followed 
by  improvement. 

Dr.  Cloetta  cannot  give  a  theory  of  the  therapeutic  action  of  cotoin ;  but  he 
has  found  that  diarrhoea,  especially  of  the  catarrhal  form,  is  arrested  in  a  short 
time  by  it;  and  he  recommends  a  trial  of  it  in  the  summer  diarrhoea  of  children. 
Pie  gives  adults  a  decigramme  (1.5  grain)  several  times  a  day;  or,  instead  of 
this,  and  with  similar  results,  3  decigrammes  (4.5  grains)  of  paracotoin. — London 
Med.  Record,  Aug.  15,  1878. 

Therapeutic  Uses  of  Coto. 
Dr.  Fronmuller  of  Flirth  contributes  to  the  Allgemeine  Medicinische  Cen- 
tral-Zeitung  of  July  10th  an  article  on  the  uses  of  coto-bark  and  its  alkaloids 


1878.] 


Materia  Medica  and  Therapeutics. 


545 


cotoin  and  paracotoin.  Since  the  middle  of  February,  1877,  he  has  administered 
coto  and  its  preparations  in  about  200  cases.  In  143  he  has  kept  tabular  accounts 
of  the  results,  taken  at  the  bedside. 

As  regards  age,  3  patients  were  between  1  and  10 ;  27  between  10  and  20 ;  65 
between  20  and  30  ;  36  between  30  and  40  ;  7  between  40  and  50 ;  and  5  between 
60  and  70.  The  diseases  from  which  the  patients  suffered  were  :  tuberculosis  of 
the  lungs,  62  cases  ;  typhus  (?  enteric),  38  ;  catarrhal  diarrhoea,  12 ;  acute  articu- 
lar rheumatism,  8  ;  gastric  disorder,  6  ;  pneumonia,  6  ;  menstrual  colic,  3 ;  bron- 
chitis, 2 ;  cedema  of  the  feet,  2 ;  catarrh,  1  ;  anorexia,  1  ;  diphtheria,  1 ; 
albuminuria,  1.  Along  with  these,  there  were  93  cases  of  severe  diarrhoea, 
mostly  colliquative,  and  91  of  excessive  sweating;  these  complications  often 
occurred  simultaneously. 

Of  the  various  preparations,  tincture  of  coto  was  given  in  109  cases  in  quanti- 
ties varying  from  15  to  500  drops  daily — the  average  amount  being  100  drops ;  in 
24  cases  cotoin  was  given,  generally  in  the  form  of  powder,  in  doses  of  H  to  4^ 
grains  several  times  daily  ;  in  5  cases,  paracotoin  was  given  in  somewhat  larger 
doses ;  and  in  5  cases  coto-pith. 

The  clinical  use  of  the  preparations  of  coto  was  for  the  most  part  only  directed 
against  symptoms,  principally  immoderate  diarrhoea  and  excessive  sweating. 

a.  In  diarrhoea,  against  which  other  remedies  had  for  the  most  part  proved 
useless,  coto  was  given  in  92  cases — 85  times  in  the  form  of  tincture.  The 
diarrhoea  was  mostly  colliquative,  following  typhus  and  tuberculosis.  In  50  cases 
the  diarrhoea  was  stopped ;  it  was  diminished  in  26  ;  and  the  remedy  remained 
without  effect  in  9  cases.  Of  the  50  successful  cases,  13  had  doses  varying  from 
10  to  50  drops;  12  from  50  to  100  drops  ;  and  25  from  100  to  500  drops,  in  the 
course  of  the  day.  Of  the  9  unsuccessful  cases,  4  had  from  10  to  50  drops;  3 
from  50  to  100  drops  ;  and  2  from  100  to  500  in  the  day.  After  some  days,  the 
symptoms — especially  colliquative  diarrhoea — returned,  but  could  be  again 
arrested  ;  frequently,  however,  the  evacuations  soon  became  normal. 

It  thus  appears  that  the  best  results  were  obtained  with  large  doses.  The 
tincture  (1  part  of  coto-bark  in  9  of  alcohol  at  85  per  cent.)  was  used  sometimes 
pure,  sometimes  mixed  with  water,  and  generally  was  readily  taken.  It  some- 
times only  happened  that  the  patients  complained  of  burning  and  irritation  in  the 
throat,  especially  when  full  doses  of  the  tincture  as  prepared  in  the  dispensary 
were  given.  The  tincture  prepared  by  Merk  of  Darmstadt  was  milder  and  easier 
to  take.  A  special  advantage  of  this  remedy  is,  that  it  is  very  well  borne  and 
generally  increases  the  appetite,  while  the  other  ordinary  astringents,  such  as 
opium,  tannin,  nitrate  of  silver,  etc.,  usually  produce  very  unpleasant  effects  on 
digestion  or  on  the  sensorium.  The  average  dose  is  50  drops  three  times  a  day, 
either  pure  or  with  sugar  or  water. 

b.  As  regards  immoderate  sweating,  Dr.  Fronmiiller  observed  in  the  case  of  a 
phthisical  patient,  suffering  at  the  same  time  from  colliquative  diarrhoea  and 
sweating,  that,  under  the  use  of  full  doses  of  tincture  of  coto,  both  these  symp- 
toms disappeared.  After  this,  he  gave  tincture  of  coto  in  91  cases  of  excessive 
sweating  ;  in  34  with  complete,  in  36  with  partial  success,  and  in  21  without 
result.  The  beneficial  action  of  coto,  which  seems  to  have  as  its  basis  the  raising 
of  the  energy  of  the  bloodvessels  of  the  skin,  generally-  lasted  only  one  night,  but 
often  for  a  longer  time.  Digestion  was  not  interfered  with  ;  the  appetite  was  in- 
deed often  increased,  so  that  Dr.  Fronmiiller  was  led  to  give  the  tincture  as  a 
stomachic  in  the  morning  in  some  cases  of  anorexia.  This  absence  of  any 
injurious  effect  on  digestion  gives  coto  a  great  advantage  over  other  remedies  used 
to  arrest  sweating,  such  as  tannin,  lead,  nitrate  of  silver,  aconite,  alum,  etc. 

Dr.  Fronmiiller  has  given  cotoin  and  paracotoin  in  eighteen  cases  of  diarrhoea, 
No.  CLII  Oct.  1878.  35 


546 


Progress  of  the  Medical  Sciences. 


[Oct. 


of  various  forms;  in  nine  with  complete  and  in  six  with  partial  success,  and  in 
three  without  result.  He  has  also  given  them  in  eighteen  cases  of  night-sweat ; 
in  eight  with  complete,  in  nine  with  partial  success,  and  in  one  without  result. 
Paracotoin  was  given  in  five  cases ;  cotoin  in  thirty-one. 

The  addition  of  concentrated  nitric  acid  to  urine  passed  about  six  hours  after 
the  administration  of  cotoin  produced  a  red  colour,  which,  however,  was  no 
longer  observed  a  few  hours  later. — London  Med.  Record,  August  15,  1878. 


MEDICINE. 

Local  Temperature, 
M.  Peter  lately  communicated  to  the  Academie  de  Medecine  an  interesting 
note  on  local  temperatures.  He  has  found  that  in  pleurisy  the  parietal  tempera- 
ture is  always  higher  than  the  average  parietal  temperature,  which  is  35.8°  C. 
(96°  F.).  The  local  increase  is  from  half  a  degree  to  2°  C.  higher,  and  may 
even  rise  still  more.  The  elevation  increases  with  the  effusion,  and  decreases 
during  the  stationary  period  of  the  effusion,  but  in  general  the  parietal  tempera- 
ture of  the  affected  side  is  from  .5°  to  1.5°  C.  higher  than  the  opposite  side. 
The  local  temperature  gradually  falls  when  the  effusion  undergoes  spontaneous 
absorption,  but  remains  several  tenths  of  a  degree  higher  than  that  of  the  normal 
side.  This  persistence  of  the  local  elevation  explains  the  possibility  of  a  relapse. 
In  cases  of  pleurisy  without  effusion  the  local  rise  is  less  than  in  cases  with 
effusion,  and  the  return  of  the  normal  temperature  is  more  rapid.  The  degree  of 
elevation  of  the  local  temperature  is  greater  than  that  of  the  axillary  temperature, 
and  the  local  precedes  the  axillary  rise — a  fact  which  demonstrates  the  influence 
of  the  local  process  on  the  general  temperature.  When  the  effusion  is  removed 
by  paracentesis,  a  sudden  local  rise  of  temperature  occurs,  which  is  explained  by 
M.  Peter  as  due  to  the  sudden  hyperannia  of  the  vessels  from  which  the  preceding 
pressure  has  been  withdrawn :  and  this  hypersemia  explains  not  only  the  more 
abundant  cells  of  the  second  effusion,  but  also  the  syncope,  pulmonary  congestion, 
and  dyspnoea  sometimes  observed  when  a  large  quantity  of  fluid  is  suddenly  re- 
moved.—  Lancet,  July  13,  1878. 

Ergot  in  7)/pJwid  Fever. 
M.  Siredey  (Journal  de  M4decine  et  de  Chirurgie  Pratiques,  February. 
1878)  gives  an  account  of  a  young  man,  aged  20,  who  recovered  from  a  very 
severe  attack  of  fever  after  the  use  of  ergot.  The  patient  entered  the  Hopital 
Lariboisiere  on  the  tenth  or  twelfth  day  of  the  disease.  The  tongue  war-  very 
dry  and  brown,  the  gums  were  covered  with  sordes,  speech  was  difficult,  and  the 
ideas  were  confused.  At  night  the  patient  had  constant  delirium,  with  subsultus 
and  other  nervous  phenomena,  great  pain  in  the  back  of  the  neck,  opisthotono- 
at  times,  and  symptoms  like  meningitis.  The  next  day  the  abdomen  was  re- 
tracted, and  signs  of  collapse  seemed  to  portend  early  death.  M.  Siredey.  bear- 
ing in  mind  the  success  attained  by  M.  Duboue  (of  Pau)  in  the  treatment  of 
ataxo-adynamic  cases  by  ergot,  prescribed  30  grains  to  be  taken  during  the  day. 
On  the  following  morning  the  muscular  twitchings  had  ceased,  the  abdomen  was 
less  drawn  in,  and  the  general  condition  was  improved.  The  ergot  was  continued 
for  three  days,  after  which  the  indications  of  danger  entirely  disappeared,  and  the 
fever  ran  its  course  with  moderate  intensity. 


1878.] 


Medicine. 


547 


M.  Duboue  recommends  ergot  in  typhoid  feTer  for  reasons  deduced  from  its 
physiological  action,  and  in  one  of  his  works  (De  quelques  Principes  fonda- 
mentauz  de  la  The'rapeutique)  cites  seven  cases  in  which  it  was  employed  suc- 
cessfully. One  patient,  a  woman,  who  was  three-and-a-half  months  pregnant, 
was  treated  with  ergot  for  fifteen  days,  and  recovered  without  miscarriage, 
although  she  took  a  daily  dose  of  22  to  30  grains  of  the  drug. — London  Med. 
Record,  June  15,  1878. . 

Peripheral  Hysteria. 

In  the  June  number  of  the  Archives  Ge'ne'rales  de  Me'dicine,  there  is  a  paper 
by  Professor  Lasegue  on  certain  local  manifestations  of  hysteria,  which  he 
terms  "  hy stories  periph&ralesy  We  must  admit,  says  the  writer,  that  the 
origin  of  hysteria  may  be  either  central  or  peripheral.  In  the  former  case  the 
brain  or  the  spinal  cord  may  be  the  causative  agent  of  the  hysterical  manifesta- 
tions, or.  as  is  frequently  seen,  the  two  combined.  Certain  patients  who  are 
subject  to  the  most  marked  convulsive  attacks  never  suffer  from  any  mental  dis- 
turbance whatever  ;  while  others,  who  have  been  always  free  from  every  form  of 
spasm  or  convulsion,  as  will  as  from  anaesthesia  or  hyperassthesia,  and  who  have 
never  Lad  what  is  properly  termed  a  jit,  may  nevertheless  suffer  from  many  forms 
of  cerebral  disorder,  varying  from  the  slightest  perversion  of  the  intellect  to  con- 
firmed delirium. 

It  is  not  of  any  of  these  forms  of  hysteria,  however,  that  Dr.  Lasegue  is  treat- 
ing in  the  present  paper,  but  of  those  manifestations  which  he  considers  to  have 
a  peripheral  origin.  These  manifestations,  he  says,  are  local,  non-symmetrical, 
and  without  any  tendency  to  become  symmetrical  later  ;  they  occupy  very  limited 
regions,  and  are  most  frequently  in  relation  with  but  a  limited  portion  of  the  ner- 
vous system.  Their  localization  is  not  a  matter  of  chance.  We  can  observe  the 
manner  in  which  they  begin  and  their  mode  of  evolution,  whereas  the  origin  of 
hysterical  manifestations  due  to  a  central  cause  almost  always  escapes  our  notice. 

The  author  gives  as  his  first  example  of  "peripheral  hysteria"  the  case  of  a 
girl,  fourteen  years  old,  who,  having  suffered  for  a  few  hours  from  epiphora  and 
some  redness  of  the  eyelids  after  a  playmate  had  thrown  some  sand  into  one  of 
her  eyes,  awoke  the  next  morning  writh  a  spasm  of  the  eyelids  on  that  side, 
which  rendered  it  impossible  for  her  to  open  that  eye ;  and  it  remained  closed 
during  four  months,  notwithstanding  various  remedies  were  tried.  At  the  end 
of  that  time  the  spasm  ceased  suddenly  one  night,  and  never  returned. 

Dr.  Lase-gue  considers  that  the  irritation  produced  by  the  sand  was  no  doubt 
the  immediate  cause  of  the  spasm,  but  cannot  be  regarded  as  adequate  to  account 
for  its  long  duration,  which  he  looks  upon  as  an  hysterical  phenomenon ;  and  his 
view  is  confirmed  by  the  fact  that  the  patient  became  afterwards  the  subject  of 
various  hysterical  manifestations,  although  previously  to  the  conjunctivitis  she  had 
been  free  from  anything  of  the  kind. 

Several  other  cases  are  brought  forward  as  examples  of  "peripheral  hysteria," 
provoked  by  some  local  external  cause.  One  of  Dr.  Lasegue' s  patients,  whose 
voice  and  singing  were  much  admired,  suffered  for  nearly  two  years  from  com- 
plete extinction  of  voice,  and  this  came  on  during  her  convalescence  from  a  very 
slight  attack  of .  bronchitis,  which  had  not  affected  the  voice,  or  but  very  little. 
Another,  after  an  attack  of  indigestion,  fearing  to  bring  on  the  pain  again,  re- 
fused to  touch  either  food  or  drink  for  twenty-four  hours  ;  and  when  at  the  end 
of  that  time  she  attempted  to  drink  a  cupful  of  milk,  the  whole  came  back,  evi- 
dently in  consequence  of  a  constriction  of  the  pharynx  or  oesophagus.  This  con- 
striction lasted  for  some  weeks,  and  even  after  it  ceased  the  spasm  would  return 
occasionally.    Space  will  not  allow  us  to  enumerate  the  many  other  examples  of 


548 


Progress  of  the  Medical  Sciences. 


[Oct. 


peripheral  hysteria  cited  in  Dr.  Lasegue's  interesting  paper.  He  concindes  by 
saying  that  it  is  evident  there  are  certain  subjects  in  whom  the  slightest  traumatic 
irritation  may  determine  a  spasm  of  exceptional  obstinacy.  Such  spasms  he 
would  designate  rather  by  the  name  of  hysteroid  than  hysterical.  If  thev  are 
found  in  certain  cases  to  be  merely  the  precursors  or  successors  of  the  ordinary 
hysterical  "attacks;"  they  may  also  be,  for  some  years  at  any  rate,  the  only 
manifestations  of  the  disease. — London  Med.  Record.  Aug.  15,  1878. 

Death  from  Goitre. 

An  extremely  interesting  monograph  on  Death  from  Goitre  and  the  Radical 
Cure  of  Goitre,  by  Professor  Rose,  just  published  by  Hirschwald,  throws  a  new 
light  upon  the  cause  of  sudden  death  in  goitrous  persons  which  has  been  fre- 
quently observed,  and  sometimes  in  the  course  of  operation.  In  three  such  cases, 
Pose  has  found  that  the  pressure  of  the  increased  thyroid  has  led  to  the  fatty 
degeneration  of  the  cartilaginous  rings  of  the  trachea,  thus  transforming  the  rigid 
and  resisting  cylinder  of  the  air-tube  into  a  membranous  and  flaccid  canal.  A 
sudden  movement  of  torsion  or  of  flexion  of  the  head  suffices,  then,  to  make  an 
elbow  in  the  tube  and  flatten  its  lumen.  This  change  is  also  accompanied  by 
fatty  degeneration  and  dilatation ;  and  thus  we  have  here  all  the  conditions  of 
sudden  death,  especially  under  anaesthesia,  or  during  the  brusque  movements  of 
the  head  and  neck  while  an  operation  is  being  performed. — British  Med.  Journ., 
July  20,  1878. 

Tartar  Emetic  in  Pneumonia. 

In  a  case  of  pneumonia  recently  treated  af  La  Charite  by  Prof  Hardy,  he  re- 
sorted to  the  practice  of  administering  large  doses  of  tartar  emetic,  once  so  com- 
mon in  Italy  and  France.  The  patient  was  nineteen  years  of  age.  and  exhibited 
well-marked  signs  of  pneumonia  of  a  very  serious  eharacter.  Speaking,  in  his 
lecture  on  the  case  (Gaz.  des  Hop.,  June  29  and  31 ),  on  the  prognosis  and  treat- 
ment, Prof.  Hardy  observed  that  there  were  some  reasons  for  regarding  it  a-  a 
very  serious  one.  The  face  of  the  man  (hitherto  in  good  health)  was  very  pallid, 
and  his  constitutional  powers  were  much  shattered,  while  faeial  herpes,  which  in 
pneumonia  is  always  of  very  bad  augury,  manifested  itself.  Fever  was  also  very 
intense,  for  while  in  pneumonia  the  pulse  ordinarily  oscillates  between  100  and 
110,  here  it  reached  120.  The  respirations  oscillated  between  40  and  50,  and  there 
was  considerable  dyspnoea.  The  lower  three-fourths  of  the  lung  were  gravely 
affected,  and  the  crepitant  rales  at  the  upper  portions  indicated  that  the  disease 
continued  to  progress. 

What  treatment  was  most  likely  to  save  the  patient  ?  Bouillaud's  repeated  bleed- 
ings can  only  be  resorted  to  during  the  first  four  or  five  days,  and  here  the  sixth  had 
been  reached,  while  the  lad  was  young  and  very  weak,  and  the  pallor  of  his  face, 
which  resembled  that  seen  in  the  third  stage  of  phthisis,  was  sufficient  to  contra-indi- 
cate  these.  Blisters  would  be  required,  but  would  not  suffice  ;  and  alcohol,  although 
a  very  useful  means,  does  not  cure  pneumonia,  but  only  furnishes  the  patient  with 
strength  enough  to  await  the  end  of  his  disease,  enabling  him  to  last  longer  than 
it,  and  to  become  cured  of  it.  It  is  not  a  means  by  the  aid  of  which  we  can  act 
directly  against  the  condition  of  the  lung.  While  passing  these  various  means  in 
review,  it  occurred  to  Prof.  Hardy  to  have  recourse  to  the  old  practice  of  giving 
large  doses  of  tartar  emetic.  But  he  did  not  adopt  it  in  the  old  centro-stimulant 
sense  of  the  Italian  school.  In  his  opinion  the  antimony  does  not  excite  any  spe- 
cial action  on  an  inflammatory  disease,  but  induces  merely  vomiting  and  purging ; 
and  so  far  from  seeking  to  obtain  "the  tolerance"  of  the  remedy  formerly  sought 


1878.] 


Medicine. 


549 


for.  even  by  combining  it  with  opium,  it  is  his  object  to  produce  the  evacuant 
effect  in  the  most  marked  manner.  To  this  end  he  orders  from  twenty-five  to 
thirty  centigrammes  in  a  mucilaginous  mixture,  of  which  a  tablespoonful  is  taken 
every  hour  or  two  hours,  following  each  dose  by  a  tepid  tisane  or  sugar  and  water, 
in  order  to  produce  efficient  vomiting  and  purging.  But  when  vomiting  has  been 
produced  three  times,  and  purging  four  times,  he  leaves  off  the  medicine  for  fear 
of  producing  too  much  depression.  In  the  present  case  but  two  tablespoonsfuls 
of  the  mixture  had  to  be  given  before  sufficient  vomiting  and  purging  were  pro- 
duced. And  on  the  evening  of  the  day  on  which  it  was  given  the  temperature 
sank  considerably,  and  by  twenty-four  hours  after  the  antimony  was  commenced 
it  had  sunk  from  4(>c  C.  to  37.  7C.  the  pulse  falling  to  70.  The  breathing  was 
easy  and  the  physical  signs  were  far  more  favourable.  A  mixture  consisting  of 
twenty-five  grammes  of  brandy  was  then  prescribed  in  order  to  keep  up  his 
strength,  and  the  next  day  the  thermometer  indicated  36.7°,  and  the  pulse  was 
only  66  :  and  by  forty-four  hours  after  the  antimony  had  been  taken  the  lung  had 
returned  almost  to  its  normal  condition. 

The  case  is  very  interesting  in  a  clinical  and  therapeutical  point  of  view;  for 
when  we  leave  pneumonia  to  itself,  merely  keeping  up  the  strength  of  the  patient 
by  brandy  and  wine,  an  abatement  of  the  lever  takes  place,  but  the  amelioration 
is  only  temporary,  and  it  returns.  That  was  seen  recently  in  the  hospital  in  a 
case  of  pneumonia  at  its  fourth  day,  with  a  temperature  of  39.8°,  and  in  which, 
by  means  of  cupping  and  the  administration  of  alcohol,  the  temperature  was  re- 
duced on  the  sixth  day  to  3  7.5°.  Next  day,  however,  the  thermometer  had  risen 
again  to  rather  higher  than  38°.  This  was  very  different  from  the  rapid  defer- 
vescence which  took  place  in  the  present  case.  In  that  case  also,  although  the 
patient  might  be  considered  as  cured,  having  neither  cough  nor  oppression  of 
breathing,  still,  five  or  si^  days  after  the  disappearance  of  fever,  the  persistence 
of  the  physical  signs  attested  the  presence  of  hepatization  of  the  lung.  So  it  is, 
in  fact,  in  the  subjects  of  pneumonia,  who  are  treated  in  this  manner — that  is, 
when  disease  is  left  to  itself,  or  when  attempts  are  confined  to  husbanding  the 
strength,  the  general  phenomena  are  found  to  cease,  and  the  local  ones  are 
amended,  but  the  physical  signs  persist.  In  the  case  which  is  the  subject  of  the 
lecture,  on  the  contrary,  it  is  the  anatomical  condition  of  the  lung  itself  which  has 
been  modified  by  the  treatment — so  that  in  forty- eight  hours  after  the  tartar  emetic 
was  given  all  physical  signs  had  disappeared.  "  The  fact  proves  in  a  very  posi- 
tive manner  the  real  efficacy  of  energetic  treatment,  whether  by  bleeding  or  by 
tartar  emetic,  administered  as  I  have  described.  You  may  be  persuaded  that,  if 
this  latter  treatment  had  not  been  had  recourse  to,  the  disease  would  have  con- 
tinued ;  and  if,  by  the  fact  even  of  its  evolution,  the  fever  had  declined,  we  should 
still  have  continued  to  observe  in  the  lung  the  physical  signs  which  characterize 
pulmonary  hepatization." — Med.  Times  and  Gaz.,  Aug.  10,  1878. 

Sudden  Death  by  Embolism. 

In  the  Archives  Generates  de  Medecine  (June,  1878)  Dr.  Terrillon  gives  the 
details  of  two  cases  in  which  sudden  death  was  caused  by  embolism  in  the  right 
side  of  the  heart.  Theoretically  such  a  possibility  has  been  admitted  by  many 
pathologists  and  clinical  teachers,  but  confirmation  of  the  theory  has  hitherto  been 
wanting  or  imperfect.  The  first  case  cited  by  Dr.  Terrillon  is  borrowed  from  M. 
Tillaux,  surgeon  at  the  Lariboisiere  Hospital  in  Paris.  A  woman,  56  years  of  age, 
came  under  M.  Tillaux' s  care  for  a  fracture  of  the  fibula  and  internal  malleolus. 
The  foot  was  partially  dislocated  outwards,  and  the  skin  was  very  tense  over  the 
malleolus,  but  without  abrasion.    The  dislocation  having  been  reduced,  plaster  of 


550 


Progress  of  the  Medical  Sciences. 


[Oct. 


Paris  splints  were  applied,  and  everything  went  on  satisfactorily  till  the  twenty- 
third  day  after  the  accident,  when  the  limb  was  found  to  be  painful  and  swollen. 
This  condition  M.  Tillaux  thought  might  be  due  to  pressure  from  the  bandages, 
which  he  therefore  loosened,  and  the  patient  was  immediately  relieved.  Twenty 
days  later  (forty- three  days  after  the  accident),  suddenly  at  the  time  of  the  doc- 
tor's visit,  the  patient,  without  having  made  the  slightest  movement,  turned  pale 
and  ceased  to  breathe.  After  one  or  two  minutes,  consciousness  returned  rapidly, 
and  she  was  able  to  give  an  account  of  her  sensations.  Dr.  Tillaux  had  scarcely 
gone  the  distance  of  a  few  beds,  when  a  second  and  mortal  syncope  occurred.  At 
the  necropsy,  a  thrombosis  was  found  filling  up  the  popliteal  and  femoral  veins  as 
far  as  the  crural  arch  ;  the  clot,  which  was  adherent  to  the  walls  in  almost  its  whole 
extent,  was  free  above,  fibrinous,  and  terminated  in  the  form  of  a  serpent's  head. 
The  pulmonary  artery  was  free,  the  lungs  sound,  except  for  a  slight  congestion  of 
the  left.  The  heart  was  loaded  with  fat.  The  right  ventricle  coutained  a  clot 
about  two  centimetres  long,  twisted  in  the  columnae  caraese.  When  this  clot  was 
compared  with  that  in  the  femoral  vein,  it  was  manifest  to  every  one  that  the  car- 
diac embolon  was  a  fragment  of  the  crural  clot. 

The  second  case  is  that  of  a  man  who  came  under  Dr.  Terrillon's  care  for  mul- 
tiple fistula?  in  the  region  of  the  coccyx,  with  extensive  disease  of  that  bone  and 
of  the  sacrum.  Resection  of  the  one  (its  point  excepted,  which  adhered  to  the 
fibrous  ligament  of  the  perineum)  and  mgination  of  the  other  were  performed, 
the  patient  being  under  chloroform.  The  dressing  was  water  and  carbolic  acid, 
and  every  morning  Dr.  Terrillon  himself  syringed  out  the  wound  with  the  same 
fluid.  The  patient's  general  health  greatly  improved,  and  the  wound  was  healing, 
when  one  morning,  being  desired  by  Dr.  Tillaux  as  usual  to  turn  on  his  side,  he 
did  so,  and  then  remained  immovable.  All  means  were  tried  to  rouse  him,  with- 
out success.  He  took  two  or  three  deep  inspirations,  the  pulse  beat  feebly,  the 
eyes  were  half  shut,  the  face  and  lips  violet,  there  was  no  agony,  and  he  died 
without  having  uttered  a  sound. 

The  necropsy  soon  revealed  the  cause  of  this  sudden  death.  All  the  veins  sur- 
rounding the  diseased  parts  of  the  bones  were  full  of  clots  and  bathed  in  pus.  The 
great  veins  of  the  pelvis,  however,  were  intact,  viz.,  the  femoral,  hypogastric  and 
inferior  vena  cava.  The  left  side  of  the  heart  was  intact  and  in  systole.  It  con- 
tained a  few  drops  of  blood,  but  no  clots.  The  right  side,  on  the  contrary,  con- 
tained, between  the  tricuspid  valves,  a  clot  about  ten  or  twelve  centimetres  (four 
or  five  inches)  long,  cylindrical  in  form,  scarcely  as  thick  as  a  quill,  entangled  in 
the  chorda?  tendinete,  and  projecting  in  one  direction  into  the  auricle,  in  the  other 
into  the  ventricle.  The  pulmonary  arteries,  examined  with  great  care,  even  in 
their  smallest  ramifications,  contained  no  trace  of  clots,  only  dark  liquid  blood  in 
abundance. 

Dr.  Terrillon  considers  the  clot  found  in  the  right  ventricle  as  the  result  of  an 
embolon  from  the  veins  of  the  pelvis  and  sacral  region,  which  were  evidently  in 
an  abnormal  state.  The  clot  had  the  appearance  and  cluster  of  an  old  clot.  It 
was  gray,  not  white  and  gelatinous,  like  those  formed  in  the  heart  at  the  moment 
of  death.  The  bifurcation  was  quite  distinct,  and  indicated  that  it  must  have 
come  from  a  vein  formed  by  the  anastomosis  of  two  smaller  veins. 

Is  not  the  kind  of  death  itself  a  sufficient  proof  that  the  clots,  having  come  from 
some  part  of  the  venous  system,  had  stopped  in  the  heart  ?  M.  Charcot,  who  saw 
the  specimen  at  the  Societe  Anatomique,  did  not  hesitate  to  say  that  he  looked 
on  this  clot  as  an  embolon  which  had  stopped  in  the  heart,  and  become  the  cause 
of  death  by  impeding  the  action  of  the  tricuspid  valve. 

Dr.  Terrillon's  conclusions  are  the  following.  1.  An  embolon  from  the  gene- 
ral venous  system  may  stop  in  the  heart  instead  of  going  into  the  pulmonary 


1878.] 


Medicine. 


551 


artery,  as  it  is  generally  admitted  it  may  do.  2.  It  may  induce  sudden  death  by 
apparent  syncope,  but  there  are  certain  phenomena  which  differ  from  the  ordinary 
syncope,  such  as  cyanosis  of  the  face  and  lips,  swelling  of  the  veins  in  the  neck. 
The  heart  does  not  stop  suddenly,  but  its  pulsations  become  all  at  once  tumultuous, 
small,  hardly  perceptible,  while  the  pulse  is  thread-like.  After  a  few  minutes,  the 
heart  stops  completely.  3.  There  is  no  respiratory  anxiety  at  the  moment  of 
death,  no  orthopnoea,  as  in  embolism  of  the  pulmonary  artery.  On  the  contrary, 
the  patient  dies  without  any  apparent  struggle.  4.  When  death  has  been  pre- 
ceded by  transitory  symptoms  of  apparent  syncope,  or  in  the  case  of  patients  suf- 
fering from  phlebitis,  we  may  suppose  that  a  very  slender  or  soft  clot  was  stopped 
for  an  instant  between  the  chordae  tendineae  of  the  tricuspid  valve  and  has  given 
rise  to  those  accidents. — Lond.  Med.  Record,  Aug.  15,  1878. 

Diseases  of  the  Diaphragm. 
The  diaphragm  is  a  muscle  the  functions  of  which  are  of  such  importance  that 
it  is  a  matter  of  some  surprise  that  so  little  attention  has  been  paid  to  its  diseases. 
With  the  single  exception  of  the  heart,  no  muscular  structure  of  th*e  body  is  in 
such  constant  action,  and  no  muscle  has  so  great  influence  on  the  functions  of 
important  viscera.  And  yet  until  now  very  few  observations  have  been  made 
upon  its  morbid  states,  and  the  student  will  search  in  vain  for  any  important  facts 
regarding'its  diseases,  with  the  exception  of  a  few  valuable  and  suggestive  obser- 
vations recorded  in  our  columns  some  ten  years  ago  by  Mr.  Callender.  In  the 
last  number  of  Virchow's  Archiv,  however,  is  an  account  of  some  observations 
by  Professor  Zahn,  of  Genth,  which  show  how  frequently  it  is  found  diseased, 
how  varied  are  the  morbid  changes  it  presents,  and  which  suggest  very  strongly 
that  their  influence  may  often  be  in  a  high  degree  prejudicial.  It  was,  indeed, 
the  observation  of  some  cases  in  which  slight  bronchitis  and  emphysema,  with 
congestion  of  organs,  and  simple,  moderate  dilatation  of  the  right  ventricle, 
seemed  insufficient  to  account  for  death,  but  in  which  marked  degeneration  of 
the  diaphragm  coexisted,  which  led  Zahn  to  study  the  condition  of  the  diaphragm 
in  other  cases. 

The  result  was  the  discovery  that  a  degenerated  state  of  the  muscular  fibres  is 
by  no  means  infrequent.  The  changes  observed  were  of  several  kinds — simple 
brown  atrophy,  with  proliferation  of  cells  and  nuclei,  and  granular  clouding,  with 
fatty  and  vitreous  degeneration  of  the  fibres.  The  former  appears  to  be  the 
more  frequent,  although  the  least  important.  It  is  not  easily  recognized  with 
the  naked  eye,  the  muscular  tissue  appearing  merely  thinner  than  normal,  and 
somewhat  pale.  The  peritoneum  covering  it,  when  stripped  off,  has  a  brown 
colour,  and  between  the  muscular  fasciculi  collections  of  fat  exist.  The  micro- 
scope reveals  greatly  degenerated  fibres,  lying  among  others  nearly  normal. 
The  former  have  lost  their  striation,  and  contain  many  granules  and  spherules, 
much  less  numerous  than  those  which  characterize  fattydegeneration,  and  the 
smaller  disappearing  under  acids.  About  the  nuclei  are  accumulations  of  yel- 
lowish granular  pigment,  sometimes  separating  proliferated  nuclei.  A  peculiar 
protoplasm- like  substance  sometimes  surrounds  the  nuclei,  or  lies  in  the  muscular 
fibres,  giving  them  a  peculiar  appearance,  and  in  places  occupying  peculiar  lateral 
bulgings  of  the  wall,  and  these  containing  numerous  nuclei.  These  bulgings  may 
be  so  numerous  as  to  be  in  contact.  The  proper  tissue  of  the  fibres  so  affected  is 
always  more  or  less  degenerated.  During  two  months  Zahn  met  with  no  less 
than  twenty  cases  in  which  this  brown  atrophy  of  the  diaphragm  was  more  or  less 
marked.  Almost  all  of  the  individuals  presenting  it  were  over  fifty  years  of  age  ; 
all  were  considerably  emaciated;  in  most,  other  organs  presented  also  simple 


552 


Progress  of  the  Medical  Sciences. 


[Oct. 


atrophy ;  and  in  all  the  muscular  substance  of  the  heart  presented  distinct  brown 
atrophy.  The  cause  of  death  in  most  was  senile  emphysema  and  bronchitis, 
catarrhal  pneumonia,  or  some  tubercular  disease  of  the  intestine  :  in  one  cancer 
of  the  oesophagus.  In  all  some  causes  had  produced  a  state  of  chronic  marasmus. 
Zahn  conjectures  that  the  condition  of  the  fibres  may  have  arisen  from  a  degene- 
ration of  the  contractile  element  and  an  imperfect  attempt  at  restorative  growth 
in  the  cells  of  the  muscle. 

The  granular  and  fatty  degeneration  of  the  diaphragm  gives  it,  as  seen  through 
the  peritoneum,  a  pale  and  somewhat  opaque  appearance,  and  when  intense, 
minute  yellowish  spots  may  be  seen  among  the  muscular  bundles.  Microscopical 
examination  shows  that  the  degeneration  affects  almost  all  the  fibres,  and  presents 
its  usual  appearance,  the  change  in  different  fibres  being,  however,  far  from  uni- 
form. In  some  the  granules  are  very  fine  and  closely  set.  The  muscle-cells 
present  no  proliferation  in  young  persons,  but  in  the  old  the  fatty  degeneration 
may  be  accompanied  by  cell-proliferation,  with  or  without  a  deposit  of  pigment. 
Protoplasm  surrounding  the  nuclei  is,  however,  in  this  case  crammed  with  fat- 
globules.  This  change  Zahn  found  twice  in  nine  cases,  each  individual  being 
over  eighty  years  of  age.  Callender  recorded1  six  cases  of  fatty  degeneration 
found  in  subjects  of  various  ages.  In  all  it  was  associated  with  marked  fatty 
degeneration  of  the  heart,  while  the  other  voluntary  muscles  were  healthy.  To 
these  cases  Zahn  adds  nine  others,  five  over  fifty,  and  four  under  forty.  All  pre- 
sented the  traces  of  more  or  less  bronchitis  and  emphysema,  and  some,  croupous 
pneumonia.  In  the  latter  cases  there  was  no  fat  ty  degeneration  of  the  heart,  but 
in  all  the  others  the  heart  and  the  diaphragm  presented  the  same  change. 
Putting  together  Callender's  andZahn's  cases,  we  have  ten  men  and  five  women, 
and  thus  the  affection  appears  to  be  more  frequent  in  the  male  sex. 

The  third  form  of  change — the  waxy  or  vitreous  degeneration  of  the  fibres — 
Zahn  has  found  in  one  case  only,  a  middle-aged  man  who  suffered  from  chronic 
alcoholism,  and  died  of  pneumonia.  To  the  naked  eye,  the  diaphragm  was  nor- 
mal, but  under  the  microscope  many  fibres  presented  the  change  in  its  most 
characteristic  form,  while  others  were  in  a  state  of  commencing  fatty  degenera- 
tion. No  similar  degenerations  could  be  found  in  the  heart  or  other  muscles,  but 
the  liver  was  fatty. 

The  correlation  of  these  changes  with  clinical  symptoms  has  yet.  in  a  great 
measure,  to  be  made.  One  of  the  most  important  clinical  facts  is  the  great  fre- 
quency with  which  degenerations  of  the  diaphragm  and  of  the  heart  coincide. 
The  changes  in  the  two  muscles  are  similar  in  character,  and  occur  for  the  most 
part  at  a  time  when  muscular  tissue  elsewhere  in  the  body  is  normal.  The  two 
structures  have  certain  common  physiological  conditions.  From  birth  to  death 
they  are  in  almost  uninterrupted  work,  and  each  appears  to  suffer  at  the  same 
time  from  the  same  general  cause ;  and  it  may  well  be  that  the  increased  work 
which  chronic  bronchitis  and  emphysema  throw  upon  the  diaphragm  and  heart 
may  lead,  in  some  cases,  to  the  occurrence  of  the  simultaneous  degeneration  of 
the  two  structures,  since  in  the  heart  the  change  is  found  most  intense  in  that 
portion  of  the  heart  on  which  the  greatest  work  falls — the  right  side.  An  expla- 
nation of  the  origin  of  the  degeneration  in  acute  lung  diseases,  in  which  com- 
monly the  heart  is  unaffected,  is  less  obvious.  All  the  conditions  of  muscular 
over-action  tend,  however,  to  produce  hypertrophy,  as  well  as,  and  even  more 
than,  degeneration.  Whether  in  these  cases  the  muscular  tissue  of  the  diaphragm 
is  increased  in  quantity  is  a  question  that  must  be  left  for  the  present  uncertain. 
The  symptoms  and  consequences  to  which  the  degenerations  give  rise  must  also 


1  The  Lancet,  1867. 


1878.J 


Medicine. 


553 


be  ascertained  by  further  observation  In  many  of  the  cases  intense  dyspnoea  had 
existed  during  life,  but  there  were  in  all  other  conditions  to  which  this  symptom 
might  be,  in  part  at  least,  ascribed.  Virchow  long  ago  pointed  out  that  atrophy 
of  the  diaphragm  increases  greatly  the  effect  of  asphyxiating  causes,  and  may  de- 
termine the  fatality  of  the  least  bronchial  catarrh.  Whether,  however,  we  may 
suggest,  this  is  true  in  cases  in  which  the  diaphragm  alone  is  affected,  the  inter- 
costals  being  normal,  is  a  point  on  which  further  observation  is  necessary,  and  on 
which  the  phenomena  of  some  cases  of  paralysis  of  the  diaphragm  throw  some 
doubt.  The  point  suggests,  however,  the  desirability  of  a  more  careful  examina- 
tion than  hitherto  has  been  made  into  the  condition  of  the  intercostal  muscles  in 
other  cases.  This  is  also  important  as  regards  the  question  of  pathogenesis, 
since,  if  overwork  plays  a  potent  part  in  the  production  of  this  change,  the  inter- 
costals  should  suffer  indue  proportion  in  the  same  cases. — Lancet,  Aug.  17,  1878. 

Paracotoin  in  Cholera. 

Dr.  Balz  of  Tokio  in  Japan  (Centralblatt  fur  die  Medicin  Wissenschaften) 
has  given  paracotoin  with  uniformly  good  result  in  five  cases  of  cholera  during 
a  recent  epidemic  ;  his  supply  then  becoming  exhausted.  It  was  used  in  sub- 
cutaneous injection  in  doses  of  2  decigrammes  (3  grains)  dissolved  in  equal  parts 
of  glycerine  and  distilled  water.  The  Japanese  government  has  decided  on  the 
extended  use  of  the  remedy,  if  an  epidemic  of  the  disease  should  again  break  out. 
The  following  brief  account  of  a  cure  speaks,  in  the  author's  opinion,  in  favour  of 
paracotoin  as  a  remedy  of  very  high  value  in  the  treatment  of  cholera — perhaps 
the  most  valuable  with  which  we  are  acquainted. 

M.,  a  strong  young  woman  aged  22,  when  seen  four  hours  after  the  commence- 
ment of  her  illness,  was  in  a  very  apathetic  condition,  with  cold  extremities  and 
thready  pulse.  She  vomited  frequently,  and  passed  rice-water  motions  involun- 
tarily. At  4  P.  M.,  2  decigrammes  of  paracotoin,  dissolved  (or  rather  suspended) 
in  equal  parts  of  water  and  glycerine,  were  injected  subcutaneously  ;  the  vomiting 
at  once  ceased.  At  5.30  she  had  a  liquid  stool ;  3  grains  of  paracotoin  were  given 
internally.  All  the  symptoms  improved,  and  the  pulse  became  stronger  and 
regular ;  the  extremities  (under  the  simultaneous  continued  use  of  warm  clothes, 
etc.)  became  warm  ;  the  cyanosis  disappeared.  Five  grammes  of  cognac  were 
given  every  quarter  of  an  hour.  Paracotoin  was  again  injected  subcutaneously  at 
midnight ;  and,  an  hour  afterwards,  there  was  profuse  sweating.  The  next  day 
the  patient  was  very  weak,  but  in  other  respects  quite  well. — London  Med. 
Record,  August  15,  1878. 

The  Diagnosis  and  Treatment  of  Jntestinal  Obstruction. 

At  the  late  meeting  of  the  British  Medical  Association  (British  Med.  Journal, 
Aug.  31,  1878),  Mr.  Jonathan  Hutchinson  read  a  paper  on  this  subject,  and 
presented  for  criticism  the  following 

Memoranda  for  Diagnosis. — 1.  When  a  child  becomes  suddenly  the  subject 
of  symptoms  of  bowel  obstruction,  it  is  probably  either  intussusception  or  perito- 
nitis. 

2.  When  an  elderly  person  is  the  patient,  the  diagnosis  will  generally  rest 
between  impaction  of  intestinal  contents  and  malignant  disease  (stricture  or 
tumour) . 

3.  In  middle  age,  the  causes  of  obstruction  may  be  various;  but  intussuscep- 
tion and  malignant  disease,  both  of  them  common  at  the  extremes,  are  now  very 
unusual. 

4.  Intussusception  cases  may  be  known  by  the  frequent  straining,  the  passage 


554 


Progress  of  the  Medical  Sciences. 


[Oct. 


of  blood  and  mucus,  the  incompleteness  of  the  constipation,  and  the  discovery  of 
a  sausage-like  tumour,  either  by  examination  per  anuni  or  through  the  abdominal 
walls. 

5.  In  intussusception,  the  parietes  usually  remain  lax,  and,  there  being  but 
little  tympanites,  it  is  almost  always  possible,  without  much  difficulty,  to  discover 
the  lump  (or  sausage-like  tumour)  by  manipulation  under  ether. 

6.  Malignant  stricture  may  be  suspected  when,  in  an  old  person,  continued 
abdominal  uneasiness  and  repeated  attacks  of  temporary  constipation  have  pre- 
ceded the  illness.  It  is  to  be  noted  also  that  the  constipation  is  often  not  com- 
plete. 

7.  If  a  tumour  be  present  and  pressing  on  the  bowel,  it  ought  to  be  discovera- 
ble by  palpation,  under  ether,  through  the  abdominal  walls  or  by  examination  by 
the  anus  or  vagina,  great  care  being  taken  not  to  be  misled  by  scybalous  masses. 

8.  If  repeated  attacks  of  dangerous  obstruction  have  occurred  with  long  inter- 
vals of  perfect  health,  it  may  be  suspected  that  the  patient  is  the  subject  of  a  con- 
genital diverticulum,  or  has  bands  of  adhesion,  or  that  some  part  of  the  intestine 
is  pouched  and  liable  to  twist. 

9.  If,  in  the  early  part  of  a  case,  the  abdomen  become  distended  and  hard,  it 
is  almost  certain  that  there  is  peritonitis. 

10.  If  the  intestines  continue  to  roll  about  visibly,  it  is  almost  certain  that  there 
is  no  peritonitis.  This  symptom  occurs  chiefly  in  emaciated  subjects,  with  ob- 
struction in  the  colon  of  long  duration. 

11.  The  tendency  to  vomit  will  usually  be  relative  with  three  conditions  and 
proportionate  to  them.  These  are  (1)  the  nearness  of  the  impediment  to  the 
stomach,  (2)  the  tightness  of  the  constriction,  and  (3)  the  persistence  or  other- 
wise with  which  food  and  medicine  have  been  given  by  the  mouth. 

12.  In  cases  of  obstruction  in  the  colon  or  rectum,  sickness  is  often  wholly 
absent. 

13.  Violent  retching  and  bile- vomiting  are  often  more  troublesome  in  cases  of 
gall-stones  or  renal  calculus  simulating  obstruction  than  in  true  conditions  of  the 
latter. 

14.  Fecal  vomiting  can  occur  only  when  the  obstruction  i-  moderately  low 
down.  If  it  happen  early  in  the  case,  it  is  a  most  serious  symptom,  as  Implying 
tightness  of  constriction. 

15.  The  introduction  of  the  hand  into  the  rectum,  as  recommended  by  Simon 
of  Heidelberg,  may  often  furnish  useful  information. 

Memoranda  for  Treatment. — 1.  In  all  early  stages,  and  in  all  acute  cases,  ab- 
stain entirely  from  giving  either  food  or  medicine  by  the  mouth. 

2.  Use  anaesthetics  promptly.  Put  the  patient  under  the  full  influence  of 
ether;  examine  the  abdomen  and  rectum  carefully  before  tympanites  has  con- 
cealed the  conditions ;  administer  large  enemata  in  the  inverted  position  of  body ; 
and,  if  advisable,  practise  abdominal  taxis.  If  you  do  not  succeed  at  first,  do  it 
repeatedly. 

3.  Copious  enemata,  aided  perhaps  by  the  long  tube,  are  advisable  in  almost 
all  cases,  and  in  most  should  be  frequently  repeated. 

4.  Fluid  injections  may  be  sometimes  replaced  by  insufflation  of  air  in  cases  of 
invagination,  since  air  finds  its  way  upwards  better,. and  is  more  easily  retained. 
It  is,  however,  somewhat  dangerous,  and  has,  perhaps,  no  advantages  over  injec- 
tions with  the  trunk  inverted. 

5.  Insufflation  is  to  be  avoided  in  all  cases  of  suspected  stricture,  since  the  air 
may  be  forced  above  the  stricture,  and  there  retained. 

6.  Saline  laxatives  are  admissible  in  certain  cases  where  impaction  of  feces  is 
suspected,  and  in  cases  of  stricture  where  fluidity  of  feces  is  advisable. 


1878.] 


Medicine. 


555 


7.  Opium  (or  morphia)  must  be  used  in  proportion  to  the  pain  which  the  pa- 
tient suffers.  It  should  be  administered  by  the  rectum  or  hypodermically,  and 
should  be  combined  with  belladonna.  If  there  be  not  much  pain  or  shock,  it  is 
better  avoided,  since  it  increases  constipation  and  may  mask  the  symptoms. 

8.  A  full  dose  of  opium  administered  hypodermically  will  put  a  patient  in  a 
favourable  condition  for  bearing  a  prolonged  examination  under  ether,  and  at- 
tempts at  abdominal  taxis. 

9.  In  cases  of  uncertain  diagnosis,  it  is  better  to  trust  to  the  chance  of  sponta- 
neous cure  of  relief  by  repeated  abdominal  taxis,  than  to  resort  to  exploratory 
operation  ;  or,  in  desperate  cases,  iliac  enterotomy  should  be  done.  Operations 
for  the  formation  of  an  artificial  anus  in  the  right  or  left  loin  may  be  performed 
whenever  the  diagnosis  of  incurable  obstructive  disease  in  the  lower  bowel  is 
made. 

10.  The  operation  for  the  formation  of  an  artificial  anus  through  the  anterior 
part  of  the  abdominal  wall  and  into  the  small  intestine  should  be  resorted  to  only 
in  certain  cases  of  insuperable  obstruction,  in  which  the  seat  of  disease  is  believed 
to  be  above  the  cascum. 

11.  In  all  cases  in  which  the  precise  seat  of  disease  is  doubtful,  but  the  large 
intestine  is  suspected,  ihe  right  loin  should  be  preferred.  If  the  colon  here  be 
found  to  be  empty,  the  peritoneum  may  be  cautiously  opened  and  a  coil  of  dis- 
tended small  intestine  brought  into  the  wound. 

12.  My  last  suggestion  as  to  treatment  is  one  which,  speaking  as  I  do  in  a 
Medical  Section,  I  feel  some  delicacy  in  making.  It  is,  however,  I  believe,  a 
very  important  one,  and  it  is  this,  that  cases  of  mechanical  obstruction  are  really 
surgical  and  not  medical  cases.  They  require  manipulative  measures  both  for 
diagnosis  and  for  treatment,  and  they  require  them  early.  It  is  difficult  to  explain 
why  it  has  come  about  that,  as  a  rule,  a  physician  is  called  in  first,  and  nothing 
but  drug  treatment  usually  adopted  in  the  early  periods ,  and  it  is,  I  am  con- 
vinced, much  to  be  regretted.  The  surgeon  is  but  too  often  asked  to  see  the  case 
only  in  the  last  stage,  when  it  is  thought  that  perhaps  an  operation  may  be  desira- 
'ble.  At  this  period  the  abdomen  is  distended,  and  an  accurate  diagnosis  imprac- 
ticable ;  but,  what  is  worse,  the  stage  at  which  abdominal  taxis  is  most  hopeful 
has  passed.  My  remarks  do  not,  of  course,  apply  when  the  medical  attendant 
possesses  the  knowledge  and  exercises  the  functions  of  both  branches. 

Mr.  Hutchinson  submitted,  as  a  most  important  proposition,  that,  in  the  present 
state  of  surgical  knowledge,  exploratory  operations  for  the  relief  of  abdominal 
obstruction,  the  cause  of  which  cannot  be  diagnosed,  are  not  warrantable.  Ope- 
rations performed  at  the  hernial  regions,  in  search,  it  may  be,  for  suspected  reduc- 
tion en  masse,  are,  of  course,  quite  outside  this  rule.  It  refers  only  to  opening 
the  abdomen  in  the  middle,  with  the  intent  to  introduce  the  hand  and  search  for 
the  obstructed  part. 

If,  however,  we  turn  to  certain  cases  in  which  the  precise  cause  of  obstruction 
is  definitely  diagnosed,  then  a  very  different  decision  must  be  arrived  at.  In 
cases  of  invagination,  when  the  included  tract  is  long  and  when  other  measures 
have  been  exhausted,  abdominal  section  is  probably  the  best  method  of  treatment. 
Here  the  surgeon  knows  what  he  is  going  to  attempt,  and  that  in  the  majority  of 
cases  it  can  be  easily  accomplished.  The  operation  is  justifiable  at  a  compara- 
tively early  stage,  when  there  is  not  much  risk  of  rupture  of  the  bowel,  and  but 
little  difficulty  may  be  expected  in  getting  the  contents  back  into  the  abdomen. 
Yet  even  here  the  operator  encounters  the  discouragement  of  knowing  that  nature 
is  competent  to  the  cure  by  sphacelus  of  some  of  the  most  desperate  forms  of  in- 
tussusception, and  it  is  not  yet  settled  whether  leaving  them  to  this  chance  involves 
less  or  more  risk  than  operating.    My  own  opinion  is,  however,  definite;  and  in 


556 


Progress  of  the  Medical  Sciences. 


[Oct. 


any  such  case,  enemata,  insufflation,  and  other  measures  having  had  patient  and 
repeated  trials,  1  should  not  hesitate  to  open  the  abdomen.  I  have  done  this  in 
two  cases,  and  in  one  of  them  with  perfect  success ;  and  successful  cases  have  also 
been  recorded  by  Mr.  Howard  Marsh,  Mr.  Howse,  and  other  surgeons.  In  the 
peculiar  form  of  intussusception  beginning  at  the  cseum  and  advancing  until  the 
inverted  ileo-ca?cal  valve  presents  at  the  child's  anus,  I  should  suspect  that  an 
operation  will  always  be  required,  for  I  know  of  no  reliable  record  of  the  recovery 
of  such  a  case  either  by  gangrene  or  by  the  measures  to  which  we  may  apply  the 
name  of  rectal  taxis.1 

Myositis  Ossificans. 
At  the  Vienna  Medical  Society,  Docent  Dr.  Nicoladoni  (AUg.  Wien.  Med. 
Zeit.,  May  28)  presented  a  girl,  seven  years  of  age,  as  an  example  of  a  very  rare 
affection  of  the  muscles,  viz.,  ossification  of  the  muscles  of  the  trunk  and  limbs. 
The  disease  had  been  going  on  for  about  a  year,  commencing  in  the  muscles  of 
the  neck,  whence  it  extended  to  the  spine,  the  anterior  part  of  the  thorax,  and 
the  limbs.  On  each  side  of  the  spine  a  rigid  line  (sacro-spinales)  extends.  The 
scapula  is  fixed  to  the  thorax ;  and  in  the  cervical  regions  are  found  fibrous  cords 
containing  bony  plates.  The  right  knee-joint  is  contracted,  and  the  pectorales 
are  almost  entirely  ossified.  There  are  only  three  similar  cases  on  record. — Med. 
Times  and  Gaz.,  June  22,  1878. 

A  New  Parasitic  Disease  of  the  Hair. 

Under  the  name  of  "Piedra,"  a  parasitic  disease  of  the  hair,  supposed  to  be  a 
previously-known  affection,  has  been  described  to  the  Academic  des  Sciences  by 
M.  DESENNE.  It  lias  been  met  with  in  Columbia,  in  the  natives  of  the  province 
of  Cauca.  It  consists  in  small  nodosities  visible  to  the  naked  eye.  and  as  hard 
as  stone,  resisting  and  even  turning  the  edge  of  a  scalpel.  The  hair,  treated  with 
ether  and  mounted  in  glycerine,  presents  the  following  appearance  under  a  mag- 
nifying power  of  140  diameters.  The  nodules  are  placed  at  a  tolerably  regular  dis- 
tance apart,  without  being  arranged  with  any  mathematical  exactness.  They  are 
of  two  kinds,  some  surrounding  the  hair  completely,  like  a  fusiform  ring,  others 
surrounding  it  incompletely,  or  forming  nodules  on  one  side.  This  difference 
may  be  explained  by  a  different  degree  of  maturity  of  the  fungus  constituting 
them.  Under  a  higher  magnifying  power  they  are  seen  to  consist  of  a  cellular 
mass  of  polygonal  elements  .102  to  .105  millimetre  in  diameter,  and  regularly 
arranged,  their  intervals  being  indicated  only  by  a  black  line.  These  cells  have 
strongly  refracting  cells,  but  no  nuclei.  Adjacent  to  one  of  these  nodosities  a  net- 
work could  be  seen  consisting  of  little  rods  articulated  one  to  another,  and  extend- 
ing around  the  hair,  just  as  ivy  surrounds  a  column.  Some  of  these  rods  ap- 
peared to  blend  with  the  proper  substance  of  the  nodosity,  others  terminated  at 
some  distance,  either  by  an  ampulliform  swelling  or  umbellate  extremity.  Are 
these  rods  the  mycelium  of  the  fungus  which  forms  the  cellular  mass  of  the  nodule, 
or  are  they  independent  of  the  latter  ?  The  question  is  difficult  to  answer,  since 
enough  hairs  could  not  be  obtained  to  settle  it  by  experiment ;  but  it  was  evident 
the  rods  were  merely  in  juxtaposition  at  the  periphery  of  the  hair.  Xowhere  in 
the  substance  of  the  hair  could  any  trace  of  a  vegetable  parasite  be  discovered 
after  the  action  of  liquor  potassas  or  acetic  acid,  and  the  integrity  of  the  medul- 
lary canal  and  its  environment  was  evident  on  a  transverse  section  through  one  of 
the  nodules.    The  interior  of  the  nodules  was  composed  of  a  cellular  stroma  simi- 

1  My  opinions  on  this  subject  will  be  found  in  detail  in  two  papers  in  the  Jltdico- 
CMrtirgical  Transactions. 


1878.] 


Surgery. 


557 


lar  to  that  covering  the  periphery,  and  on  it  were  some  large  cavities  containing 
one  or  two  large  uncoloured  cells,  probably  three.  Similar  empty  cavities  could 
be  seen  at  certain  points  in  the  substance  of  the  nodosity,  and  had  apparently  been 
of  the  same  nature,  and  become  inclosed  by  the  layer  of  polygonal  cells. — Lan- 
cet, August  3,  1878. 


SURGERY. 

Septic  and  Aseptic  Wound-Fevers. 
One  difference  between  cases  of  surgical  operation  and  of  injuries  treated  anti- 
septieally  and  those  treated  by  the  old  methods  is,  that  in  a  large  proportion  of 
the  former,  if  successfully  managed,  there  is  no  rise  of  temperature  whatever, 
even  though  the  extent  of  wound  be  such  that  under  ordinary  circumstances  the 
fever  would  be  sufficiently  severe  to  cause  death.  On  the  other  hand,  fever,  and 
even  considerable  elevation  of  temperature,  may  occur  in  cases  where  the  wounds 
have  apparently  been  treated  with  all  the  precautions  of  antiseptic  surgery.  The 
fever,  however,  which  is  met  with  where  the  antiseptic  method  has  been  em- 
ployed, is  remarkable  tor  the  slight  constitutional  disturbance  with  which  it  is  ac- 
companied. The  elevation  of  temperature  is  almost  the  only,  or  at  any  rate  the 
only  remarkable,  clinical  symptom.  In  spite  of  their  fever,  the  patients  scarcely 
feel  ill.  This  peculiarity  of  the  fever  accompanying  antiseptic  wounds  has  been 
carefully  studied  for  several  years,  in  Professor  Yolkmaxx's  clinic  at  Halle,  by 
himself  and  Dr.  Alfred  Genzmer,  and  they  have  summed  up  the  conclusions 
which  they  have  already  arrived  at  in  No.  121  of  the  Sammlung  Klinischer 
Vortr'dge. 

To  the  fever  which  accompanies  ordinary  wounds  they  give  the  name  of  "  sep- 
tic," and  to  that  which  may  or  may  not  be  present  in  wounds  treated  antisepti- 
cally.  according  to  the  rules  laid  down  by  Professor  Lister,  that  of  ''aseptic" 
wound-fever.  Out  of  a  thousand  cases  of  severe  injury  or  severe  operations 
treated  with  complete  success  by  the  antiseptic  method,  about  one-third  will  re- 
cover, roughly  speaking,  without  any  fever  at  all,  one-third  will  have  moderate 
fever,  and  one-third  high  fever.  At  first  the  occurrence  of  fever  under  the  anti- 
septic treatment  was  considered  by  Yolkmann  to  be  due  to  some  defect  in  the 
management  of  the  dressing,  but  careful  observation  of  a  large  number  of  patients 
showed  that  after  all  those  case-  in  which  the  fever  could  be  explained  by  the 
occurrence  of  small  abscesses  in  the  neighbourhood  of  the  sutures,  by  imperfect 
drainage,  by  sloughing  of  the  edges  of  the  wound,  by  carbolic-acid  eruptions,  by 
individual  susceptibility  to  the  contact  of  the  air,  and  by  other  causes  (all  of 
which  clearly  gave  rise  to  transient  septic  infection  of  the  mildest  character), 
there  still  remained  a  large  number  of  patients  who  had  more  or  less  severe,  and 
more  or  less  protracted,  fever,  while  the  progress  of  the  wound  was  completely 
normal,  without  redness,  swelling,  purulent  discharge,  or  the  least  deviation  from 
the  typical  course  of  an  antiseptically- treated  wound. 

The  remarkable  thing  about  aseptic  fever  is  its  complete  apparent  independence 
of  the  condition  of  the  wound.  A  patient  may  have  a  temperature  ranging  from 
39.5°  to  40.5°  Cent.  (103.1°  to  104.9°  Fahr.)  for  a  week  or  ten  days,  and  yet 
appear  perfectly  well ;  in  fact,  he  may  be  able,  as  is  frequently  the  case  at  Halle 
after  wounds  or  operations  on  the  upper  extremities,  to  walk  two  or  three  miles 
from  his  home  in  the  country  every  day  to  the  hospital  to  have  the  dressing 
changed.  In  aseptic  fever,  even  with  the  highest  temperatures,  Yolkmann  and 
Genzmer  never  found  the  tongue  dry,  though  there  was  often  increased  thirst. 


558  Progress  of  the  Medical  Sciences. 


The  skin  never  felt  so  hot  to  the  touch  as  it  was  proved  to  be  by  the  thermometer, 
and  it  was  always  moist,  and  not  dry.  Profuse  sweats  were  not  unfrequent.  The 
urine  was  secreted  in  remarkable  abundance,  and  the  appetite  of  the  patient  was 
but  little,  if  at  all,  affected.  There  was  scarcely  any  decrease  in  the  excretion  of 
chlorides  ;  on  the  other  hand,  urea  was  abundantly  excreted,  the  amount  being 
apparently  proportional  to  the  intensity  of  the  fever.  The  average  relation  be- 
tween chlorides  and  urea  in  aseptic  fever  was  found  to  be  as  1:2  —  3,  and  in  sep- 
tic fever  as  1  :  10  —  18-  There  was  usually  rather  a  tendency  to  looseness  of  the 
bowels  than  to  constipation.  In  spite  of  the  fever  the  patients  lost  very  little 
flesh  or  strength.  The  frequency  of  the  pulse  corresponded  in  general  terms  to 
the  height  of  the  fever,  just  as  in  the  sceptic  form,  but  its  volume  was  never  so 
small,  nor  its  tension  so  marked,  as  it  often  is  in  the  latter. 

The  pure  form  of  aseptic  fever  is  characterized  by  Volkmann  and  Genzmer  as 
"  harmless  and  without  prognostic  significance."  Of  course  between  these  cases 
of  pure  aseptic  fever  and  the  cases  of  ordinary  septic  fever  there  are  numerous 
transitional  forms,  which  depend  most  probably  on  the  imperfection  of  the  present 
antiseptic  method,  by  which  the  development  of  specific  processes  of  decomposi- 
tion in  the  secretions  of  the  wound  is  not  always  completely  prevented.  The 
final  issue  of  such  cases  depends  on  the  predominance  of  the  septic  or  aseptic 
element. 

Cases  of  pure  aseptic  fever  are  rare  under  the  old  method  of  dressing  wound-, 
though  they  do  occur;  on  the  other  hand,  well-marked  aseptic  fever  is  not  un- 
common, according  to  Volkmann,  in  cases  of  subcutaneous  injury,  severe  con- 
tusions of  joints,  and  especially  in  subcutaneous  fractures  of  bones.  Thus,  out  of 
fourteen  cases  of  simple  fracture  of  the  thigh  recently  admitted  into  Volkmann's 
clinic,  all  but  three  were  accompanied  with  fever  ranging  from  38. 9°  to  40°  Cent. 
On  the  other  hand,  in  only  a  half  of  a  number  of  cases  of  simple  fracture  of  the 
leg  was  there  any  elevation  of  temperature.  The  smaller  proportion  of  febrile 
cases  in  the  latter  category  is  explained  by  Volkmann  to  depend  on  the  different 
mode  of  treatment  of  the  two  kinds  of  fractures  in  his  clinic,  fractures  of  the  leg 
being  either  put  up  in  plaster  of  Paris  or  in  splints,  whereas  fractures  of  the  thigh 
are  invariably  treated  by  extension  with  weights,  so  that  in  the  former  case  there 
is  less  opportunity  for  local  irritation  or  reaction  than  in  the  latter. 

But  not  only  are  subcutaneous  fractures  not  invariably,  as  some  authorities  have 
asserted,  afebrile  in  their  course,  but  the  fever  which  accompanies  them  is  not 
always  purely  aseptic  in  its  character.  Volkmann  and  Genzmer  have  noticed  this 
especially  in  fractures  of  the  neck  of  the  femur,  and  they  ask  whether  the  high 
temperature  and  the  general  septic  character  of  the  symptoms  depend  in  these 
cases  on  inflammatory  complications  which  have  been  overlooked  in  internal  organs, 
or  to  an  unusual  development  of  poisonous  exudations  between  the  surfaces  of  the 
fractured  bone.  Anyhow,  with  these  facts  before  us  it  would  be  unfair  to  demand 
that  patients  with  open  wounds  submitted  to  antiseptic  treatment  should  exhibit 
no  elevation  of  temperature  in  the  early  days  of  the  healing  process. 

The  theoretical  explanation  of  the  peculiar  behaviour  of  aseptic  wound- 
fever  we  shall  give  in  the  words  of  its  authors:  "  Aseptic  wound-fever, "  they 
say,  "is  after  all,  in  our  opinion,  nothing  but  a  fever  due  to  absorption,  but  it 
differs  from  septic  fever  in  this  respect,  that  the  substances  absorbed  are  not  so 
very  different  from  those  which  are  produced  by  the  retrograde  metamorphosis  of 
the  tissues,  and  the  various  nutritive  processes  which  occur  physiologically  in  the 
body ;  whereas,  in  septic  fever,  heterologous,  poisonous,  and  putrid  bodies  or 
fluids  which  contain  some  specific  element  or  other,  capable  of  exciting  processes 
of  decomposition,  find  their  way  into  the  blood.  The  knowledge  which  has  been 
obtained  by  experiments  on  transfusion,  and  even  on  autotransfusion,  prevents 


1878.] 


Surgery. 


559 


our  doubting  for  a  single  moment  that  such  substances  as  we  have  supposed  to  have 
given  rise  to  aseptic  fever  are  capable  of  producing  large  elevations  of  the  tem- 
perature of  the  blood." 

In  the  repair  of  all,  even  of  subcutaneous  injuries,  large  portions  of  tissue  must 
be  decomposed  and  absorbed,  and,  as  a  fact,  aseptic  fever  most  often  occurs, 
and  is  highest  and  most  protracted,  in  the  antiseptic  treatment  of  contused  and 
lacerated  wounds,  and  after  operations  resulting  in  an  excessively  large  breach  of 
surface.  It  is  a  strong  argument  in  favour  of  the  above  view  of  aseptic  fever  as 
an  absorption-fever  that  Volkmann  and  Genzmer  have  almost  invariably  suc- 
ceeded in  rendering  the  most  severe  operations  and  injuries  afebrile  by  means  of 
permanent  antiseptic  irrigation,  combined  with  abundant  drainage  of  the  deepest 
parts  of  the  wound,  so  that  the  secretions  which  form  between  the  sides  of  the 
wound  in  the  first  few  days  after  operation  are  continually  washed  away.  In  con- 
cluding their  observations,  which  they  frankly  admit  to  be  provisional  in  charac- 
ter, the  authors  point  out  that  one  result  of  their  researches  must  be  to  prevent  a 
great  part  of  the  clinical  symptoms  of  fever  being  referred  so  exclusively  to  the 
rise  in  the  temperature  of  the  blood  as  has  lately  been  so  much  the  fashion.  The 
use  of  the  thermometer  per  se  gives  very  uncertain  indications  in  antiseptic  pa- 
tients when  Ave  wish  to  determine  whether  danger  is  to  be  apprehended  from  their 
wounds,  while,  on  the  other  hand,  careful  observation  on  the  general  condition  of 
the  system  is  of  the  highest  importance. — Med.  Times  and  Gaz.,  June  22,  1878. 

Occurrence  of  a  Pustular  Eruption  in  Pijcemic  Cases. 

'Sir.  II.  C.  Cameron  relates  (in  the  Lancet,  July,  1878,  p.  65)  two  cases  of 
this  apparently  rare  complication  in  pyaemic  cases.  A  young  woman  was  ad- 
mitted into  hospital,  with  well-marked  anthrax  of  the  lower  lip,  on  October  10, 
1876,  and  died  October  12.  On  admission,  there  were  no  cutaneous  symptoms; 
but,  on  the  11th,  the  body  and  extremities  were  covered  with  sudamina,  and 
numerous  small  purpuric  spots,  that  did  not  disappear  on  pressure.  Very  soon 
the  sudamina  became  purulent. 

In  another  case,  admitted  on  May  3d,  1877,  a  young  girl,  aged  ten,  had  the 
great  toe  severely  crushed  three  weeks  previously.  Acute  peritonitis  followed. 
Over  the  whole  surface  of  the  body  an  eruption,  precisely  similar  to  that  in  the 
previous  case,  existed,  which  quickly  became  pustular ;  and,  before  her  death, 
the  body  was  covered  with  pustules  of  very  considerable  size  Dr.  Foulis,  who 
conducted  the  post-mortem  examination  in  each  case,  was  of  opinion  that  the  pus- 
tular eruption  was  due  to  capillary  cutaneous  injections. 

[This  pustular  eruption  and  purpuric  exanthem  accompanying  pyemia  are  ably 
treated  by  an  anonymous  contributor  in  the  Gazette  Hebdomadaire,  No.  46,  1868. 
The  conclusions  at  which  he  arrives  are  these  :  1.  In  cases  of  pyamiia,  the  skin 
becomes  the  seat  of  various  exanthematous  eruptions.  2.  This  symptom  is  rare, 
if  one  may  judge  from  the  silence  of  authors ;  it  is  the  avant  courier  of  approach- 
ing death.  The  late  Dr.  Anstie  reported  in  the  Lancet,  January,  1870,  p.  117, 
a  singular  case  of  spontaneous  pyaemia  occurring  in  a  scullerymaid  aged  twenty, 
admitted  Sept.  10th,  1869,  with  pain  in  her  joints,  that  had  existed  several  days. 
Temperature  101°  Fahr.  Sept.  12th.  On  the  right  side  of  her  face  were 
a  couple  of  red  spots.  On  the  13th,  over  the  face  and  body  were  a  number 
of  bullae  and  pustules  in  various  stages.  Temperature  104°.  The  left  knee  was 
much  swollen,  also  the  dorsum  of  the  right  hand.  On  Sept.  14th,  the  pustules 
and  bullae  were  still  more  numerous.  Death  occurred  at  5  P.  M.  The  post- 
mortem examination  threw  no  light  upon  the  origin  of  the  pyaemia,  which,  Dr. 
Anstie  thought,  must  have  arisen  from  the  foul  atmosphere  in  which  the  patient 
lived. — Rep.] — London  Med.  Record,  Aug.  15,  1878. 


Progress  of  the  Medical  Sciences. 


[Oct. 


Cancer. 

In  a  paper  on  cancer  read  at  the  Congress  of  the  Society  of  German  Surgeons 
in  1877,  and  subsequently  published  in  von  Langenbeck's  Archiv  fur  Klinische 
Chirurgie,  Band  xxii.  Heft  2,  Professor  Esmarch  presented  several  aphorisms 
on  the  clinical  history  of  cancerous  disease.  After  a  statement  of  the  well-recog- 
nized fact  that  the  terms  "cancer"  and  "malignant  growth"  are  no  longer  syno- 
nymous, the  author  points  out  that  growths  which  usually  take  a  benign  course 
may  occasionally  present  an  undoubted  malignant  character.  This  change  mav 
occur  in  enchondroma.  fibroma,  and  fatty  tumors ;  and,  as  has  been  recentlv 
shown  by  Cohnheim,  a  cystic  bronchocele  may  acquire  a  malignancy  equal  in  in- 
tensity to  that  of  typical  sarcoma  and  carcinoma.  Most  surgeons  of  experience 
have  had  opportunities  of  observing  cases  in  which  there  had  been  a  speedy  can- 
cerous degeneration  of  a  long-standing  wart  on  the  face  of  an  old  person.  Of 
less  frequent  occurrence,  however,  although  the  author  has  seen  four  instances  of 
this,  is  the  rapid  conversion  into  a  malignant  tumour  of  a  simple  atheroma  of  the 
scalp,  a  form  of  new  growth  commonly  regarded  as  most  benign.  Cases  of  this 
kind  were  reported  by  Dieffenbach  and  Wernher.  In  some  remarks  bearing  on 
the  clinical  facts  that  lingual  and  buccal  psoriasis  is  frequently  converted  into  a 
cancerous  ulcer,  and  that  old  scars,  especially  those  formed  after  lupoid  ulcera- 
tion, frequently  undergo  cancerous  degeneration,  the  author  puts  the  question, 
whereby  and  under  what  conditions  do  benign  new  growths  and  cicatrices  take  on 
a  malignant  character  ?  It  is  well  known  that  the  repeated  action  on  a  soft  struc- 
ture of  some  irritating  body  may  be  followed  by  the  appearance  of  a  cancerous 
growth,  and  there  can  be  no  doubt  that  the  prolonged  or  frequently  renewed  con- 
tact of  tobacco-juice,  soot,  and  paraffin  may  give  rise  to  cancroid  of  the  skin.  In 
the  great  majority  of  cases  of  cancer,  however,  no  evidence  can  be  obtained  of 
the  previous  action  of  any  irritant,  and  so  one  is  led  to  inquire  whether  the  ma- 
lignant disease  may  not  be  due  to  some  constitutional  anomaly  or  dyscrasia.  Dr. 
Esmarch  seems  disposed  to  hold  that  the  inherited  dyscrasia  of  scrofula  and 
syphilis  may  create  a  tendency  to  malignant  new  growth.  Such  an  association, 
however,  it  is  granted,  cannot  be  made  out  save  by  the  exercise  of  much  patience, 
and  the  expenditure  of  much  time  in  obtaining  complete  clinical  histories.  It  is 
stated  by  the  author  that  many  undoubtedly  malignant  tumours  may  be  cured  by 
operation,  provided  the  surgeon  interfere  early,  and  the  growth  be  radically  re- 
moved. Unfortunately,  in  too  many  case?  the  operation  is  not  performed  until 
a  late  period,  and  when  many  other  and  milder  methods  of  treatment  have  been 
tried.    In  most  of  these  cases  the  blame,  the  author  holds,  rests  with  the  patient. 

In  discussing  the  treatment  of  cases  of  advanced  cancer  in  which  surgical  ope- 
ration is  hopeless.  Professor  Esmarch  states  that,  in  his  opinion,  arsenic  is  a  very 
efficient  agent,  and  one  that  may  be  used,  internally  as  well  as  externally,  with 
the  best  effect.  The  practice  is  recommended  of  giving  Fowler's  solution  after 
removal  of  a  cancerous  growth,  in  order  to  prevent  relapse.  The  employment  of 
this  agent  is  naturally  suggested  by  what  we  know  as  to  the  nature  of  cancer. 
Arsenic  certainly  acts  beneficially  on  certain  affections  of  the  epidermis,  and 
cancer  may  be  strictly  regarded  as  an  excessive  overgrowth  of  epithelium.  It  is 
necessary  in  desparate  cases  of  cancer  to  administer  arsenic  in  rapidly  increased 
and  finally  heroic  doses.  The  good  results  recently  obtained  by  Billroth  and 
others  from  the  employment,  both  internal  and  external,  of  arsenic  in  cases  of 
malignant  lymphoma,  show  that  growths  not  of  an  epithelial  structure  may  also 
be  cured  by  this  agent,  good  results  from  the  use  of  which  have  also  been  gained 
in  the  treatment  of  cases  of  lymph o- sarcoma. 

Dr.  Esmarch  has  repeatedly  applied  electrolysis  for  the  destruction  of  cancer- 


1878.] 


Surgery. 


561 


ous  grow  ths  -which  could  not  be  totally  removed  by  operation,  but  in  only  one 
case  with  any  marked  success.  Canquoin's  paste  acts  very  efficiently  on  the  re- 
moval of  new  growths,  but  a  great  objection  to  the  use  of  this  compound  is  the 
pain  it  creates,  which  is  very  severe,  and  but  partially  relievable  by  morphia. 

In  some  remarks  on  a  reported  case  of  relapsing  sarcomatous  tumour,  treated 
successfully  by  the  use,  both  internal  and  external,  of  iodine,  Dr.  Esmarch  sug- 
gests that  many  malignant  new  growths,  especially  those  which  improve  on  the 
administration,  in  large  doses,  of  tincture  of  iodine,  may  be  associated  with  in- 
herited or  acquired  syphilis.  There  are  many  clinical  and  pathological  facts  that 
indicate  such  an  association.  All  pathologists  agree  that  it  is  very  difficult  to 
distinguish  histologically  betwreen  the  products  of  tertiary  syphilis,  the  so-called 
gummata,  or  syphilomata,  and  sarcomatous  new  growths.  The  small-celled 
infiltration  of  the  tissues  of  the  nose,  described  by  Hebra  under  the  name  of  rhi- 
noscleroma.  which  stands  midway  between  chronic  inflammatory  proliferation  and 
malignant  new  growth  is  frequently  associated  with  long-standing  syphilis.  It  is 
well  know  n,  also,  that  buccal  and  lingual  psoriasis,  which  so  often  terminates  in 
cancer  of  the  tongue,  has  frequently  a  syphilitic  origin.  It  is  acknowledged, 
however,  that  a  product  of  advanced  syphilis  or  of  scrofulosis  is  frequently  mis- 
taken for  a  malignant  new-growth,  and  that  even  by  many  an  experienced  sur- 
geon an  ulcerated  gumma  or  a  tubercular  ulcer  of  the  tongue  has  been  excised  as 
a  lingual  cancer,  a  syphilitic  ulcer  of  the  lip  as  a  labial  cancer,  and  syphilitic 
growths  from  the  mucous  membrane  of  the  rectum  as  rectal  cancer.  Mistakes  of 
this  kind  are  more  likely  to  occur,  as  it  is  not  generally  known  that  ulcerating 
gummata  may  be  met  long  after  the  date  of  the  primary  affection,  and  without 
the  appearance  during  the  interval  of  any  secondary  symptoms. 

In  consequence  of  the  probability  of  such  errors,  Dr.  Esmarch  has  made  it  a 
rule  in  his  practice  never  to  extirpate  a  morbid  growth  before  having  made  out 
its  structure  and  nature  by  microscopical  examination.  For  this  purpose,  a  very 
small  piece  removed  from  the  surface  of  the  growth  or  from  its  central  part  by 
means  of  a  proper  instrument,  will  suffice.  When  there  is  an  indication  of 
having  to  perform  an  important  and  dangerous  cutting  operation  for  the  removal 
of  a  new  growth,  the  surgeon  need  not  hesitate  to  carry  out  this  very  minor  and 
safe  preliminary  measure. — London  Med.  Record,  Aug.  15,  1878. 

v-1'   '  P 

Chloroma. 

An  example  of  the  rare  form  of  sarcoma  which,  from  its  tint,  has  been  desig- 
nated "chloroma,"  has  been  recorded  by  Huber  in  the  Arclviv  der  Heilkunde. 
It  occurred  in  a  girl,  aged  twenty-one  years,  the  primary  growth  being  in  the 
mamma.  Death  occurred  in  consequence  of  the  widespread  secondary  develop- 
ment of  the  growths,  seven  months  only  after  the  appearance  of  the  primary 
mammary  tumour,  which  was  extirpated.  At  the  autopsy  secondary  growths 
were  found  in  the  periosteum  of  the  orbit,  the  frontal  and  occipital  bones,  and  in 
the  other  mamma.  All  the  tumours  presented,  on  section,  a  yellowish-green 
tint,  here  and  there  bluish-green,  mottled  by  paler  tracts.  The  enlarged  bron- 
chial glands,  and  the  pus  which  came  from  the  wound  left  after  the  extirpation 
of  the  mamma,  had  the  same  colour.  The  structure  of  the  tumours  was  that  of  a 
round-celled  sarcoma,  through  which  passed  tracts  of  a  spindle-celled  tissue. 
The  tint  was  pale  in  thin  sections,  and  was  due  to  coloured  granules  or  drops, 
which  were  regarded  as  neither  albumen  nor  simple  fat,  but,  it  was  conjectured 
from  the  reactions,  consisted  of  a  compound  of  a  fatty  acid  with  some  organic  or 
inorganic  substance.  The  periosteal  position  of  these  growths  is  characteristic  of 
the  variety. — Lancet,  Aug.  3,  1878. 

No.  CLII  Oct.  1878.  36 


562 


Progress  of  the  Medical  Sciences. 


[Oct. 


Extirpation  of  the  Larynx ;  Artificial  Vocal  Apparatus. 

Dr.  George  Wegner  (Berlin)  described,  at  the  late  Congress  of  the  Society 
of  German  Surgeons,  the  case  of  a  woman,  aged  52,  who  was  operated  on  in 
September  of  last  year.  Tracheotomy  was  first  performed  on  account  of  severe 
dyspnoea ;  and,  the  presence  of  cancer  having  been  detected  by  laryngoscopic  ex- 
amination, the  whole  larynx  was  removed,  along  with  the  epiglottis.  The  patient 
was  now  in  good  health,  and  showed  no  signs  of  a  return  of  the  disease  She 
had  used  Gussenbauer's  artificial  vocal  apparatus  occasionally,  and  had  spoken 
distinctly  with  it.  She  could,  however,  wear  it  for  only  short  times,  as,  in  con- 
sequence of  the  fauces  being  imperfectly  shut  off  from  the  trachea,  portions  of 
food  and  mucus  readily  passed  into  the  latter,  and  interfered  with  the  play  of  the 
metallic  tongue.  The  cause  of  this  was  probably  the  removal  of  the  epiglottis, 
from  which  proceeding  Dr.  "Wegner  would  abstain  in  any  subsequent  similar  ope- 
ration, unless  it  were  found  to  be  indispensable. 

Dr.  Wegner  then  showed  the  action  of  an  artificial  vocal  apparatus  on  a  girl 
aged  11,  who,  at  the  age  of  seven,  had  an  attack  of  diphtheria,  which  was  fol- 
lowed by  cicatricial  closure  of  the  trachea  and  complete  destruction  of  the  vocal 
cords.  When  she  was  admitted  to  hospital  she  wore  a  tracheal  tube,  and  was 
quite  voiceless.  By  means  of  laryngotomy  and  the  use  of  bougies,  the  laryngeal 
passage  was  made  pervious.  Dr.  Wegner  supplied  her  with  an  apparatus,  which 
differed  from  Gussenbauer's  in  the  absence  of  the  tongue-shaped  epiglottis,  and 
further,  in  the  circumstance  that  the  voice-tube  was  introduced  first,  and  then  the 
tracheal  tube.  With  this  apparatus  she  could  speak  easily  and  distinctly. — Lon- 
don Med.  Record ,  June  15,  1878. 

Gunshot  Wound  of  the  Chest ;  Resection  of  the  Clavicle  and  Five  Ribs. 
Dr.  Schneider  (Konigsberg)  related  the  following  case  at  the  late  Congress 
of  the  Society  of  German  Surgeons  :  On  October  10th  of  last  year,  O.  H.,  aged 
21,  attempted  to  commit  suicide  by  discharging  a  pocket-pistol  loaded  with  two 
bullets  into  his  chest,  on  the  left  side  of  the  sternum,  above  the  third  rib.  .  The 
opening  was  four-fifths  of  an  inch  in  diameter  ;  and  there  was  much  laceration  of 
the  lung.  As  sufficient  care  was  not  taken  to  use  disinfectants,  the  effused  blood 
underwent  putrefaction,  and  the  ha?mato-pneumothorax  produced  by  the  wound 
became  converted  into  an  ichorous  luemato-pyo-pneumothorax.  There  was  also 
sloughing  of  the  injured  lung.  Septic  infection  was  thus  produced,  and  the  pa- 
tient became  pyasmic  ;  rigors  appeared  on  the  fourth  day  after  the  injury.  On 
October  20,  the  patient  came  under  Dr.  Schneider's  care.  Thoracentesis  was 
first  performed,  and  a  quantity  of  thin  highly  offensive  fluid  was  removed  from 
the  left  pleural  cavity  ;  an  incision  \\  inch  long  was  made  between  the  seventh 
and  eighth  ribs.  A  splinter  of  the  third  rib  was  removed,  and  the  pleural  cavity 
was  thoroughly  washed  out  with  a  solution  of  carbolic  acid  (2^  per  cent.). 
Through  the  opening  of  entrance — which  had  become  much  widened — there 
could  be  seen  the  pericardium  covering  the  upper  part  of  the  heart,  the  contrac- 
tion of  the  auricles,  and  the  pulsation  of  the  great  vessels.  As  far  as  the  lung 
could  be  seen,  it  was  everywhere  sloughing ;  the  greater  part  of  the  upper  lobe 
was  wanting.  The  subsequent  treatment  consisted  of  diligent  washing  out  of  the 
thoracic  cavity  ;  the  insertion  of  a  silver  canula  where  the  incision  had  been  made  ; 
and  dressing  with  carbolized  jute.  For  some  days  the  rigors  continued,  and  the 
patient's  appetite  was  bad.  In  consequence  of  further  sloughing  of  the  lung,  the 
posterior  wall  of  the  thorax  was  exposed,  and  the  bullets  were  detected  in  it. 
On  moving  one  of  them  with  a  probe,  it  fell  into  the  thoracic  cavity  on  to  the 
diaphragm,  and  during  the  night  the  other  bullet  also  fell.    Chloroform  having 


1878.] 


Surgery. 


563 


been  administered,  the  patient  was  placed  on  his  side,  and,  the  finger  having  been 
introduced  into  the  incision-wound,  both  bullets  were  hooked  out  ;  they  lay  on 
the  diaphragm.  The  paper  wadding,  which  had  become  infiltrated  with  sanious 
matter,  was  also  soon  afterwards  removed.  Early  in  November  the  necrosis  of 
the  lung  was  arrested,  and  the  patient  was  free  from  fever.  The  remains  of  the 
lung  gradually  contracted  towards  the  hilus ;  it  had  a  very  hard  feel,  and  was 
connected  with  firm  cicatricial  masses  of  connective  tissue.  The  aperture  of 
entrance  of  the  bullets  had  contracted  to  a  length  of  3}  inches  and  a  breadth  of 
If  inch.  As  there  was  no  trace  of  diminution  of  the  right  pleural  cavity  to 
correspond  with  the  destruction  of  a  large  portion  of  the  lung,  and  as  the  patient's 
strength  was  failing  daily.  Dr.  Schneider,  on  December  8th,  excised  from  the 
second  rib  5,  from  the  fourth  <H.  from  the  fifth  9£,  and  from  the  sixth  11  centi- 
metres (2,  3.8,  3.8,  and  4.4  inches)  at  the  junction  with  the  cartilages.  This 
extensive  resection  was  not  followed  by  the  result  which  was  expected.  A  week 
later  the  lower  part  of  the  thoracic  cavity  began  to  contract,  but  the  portion  above 
the  third  rib  (where  there  was  no  trace  of  lung)  remained  unchanged.  On  Jan. 
15th,  Dr.  Schneider  removed  (by  subperiosteal  section,  as  in  all  the  other  inci- 
sions) a  piece  of  the  clavicle  an  inch  and  a  half  long  ;  by  which  the  left  shoulder 
was  approximated  to  the  sternum,  and  the  soft  parts  in  the  infraclavicular  region 
were  drawn  more  toward  the  thoracic  cavity.  The  result  was  successful.  The 
soft  parts  in  the  cavity  contracted,  the  upper  part  of  the  pericardium  with  the 
great  vessels  retreated  towards  the  left,  and  the  upper  part  of  the  left  pleural 
cavity,  which  before  the  resection  easily  admitted  three  fingers,  at  the  beginning 
of  March  allowed  only  room  for  a  moderately  thick  bougie.  At  the  end  of 
March,'  the  whole  left  pleural  cavity  was  obliterated,  and  the  situation  of  the 
aperture  of  entrance  was  occupied  by  a  funnel-shaped  cicatrix,  and  a  small  super- 
ficial wound.  The  resection-wounds  healed  by  the  first  intention.  There  was  a 
slight  osseous  deposit  at  the  parts  where  the  ribs  had  been  excised,  and  much  on 
the  clavicle.  The  left  arm  was  freely  movable,  but  somewhat  limited  in  function 
as  compared  with  the  right  arm.  The  left  clavicle  retained  its  position ;  the 
scapula  had  somewhat  sunk;  there  was  no  trace  .of  scoliosis.  The  heart  lay 
almost  entirely  in  the  left  half  of  the  chest;  the  apex-beat,  which  was  strong,  was 
perceived  in  the  fifth  intercostal  space,  two  centimetres  outside  the  nipple.  Car- 
diac pulsations  could  be  distinctly  seen  where  the  third,  fourth,  and  fifth  ribs  had 
been  excised. 

Dr.  Bardeleben  said  that  such  cases  showed  how  much  man  could  bear.  At 
Gitschin  a  splinter  of  shell  had  torn  away  the  left  side  of  a  man's  chest,  and  his 
left  elbow  was  also  crushed.  Tetanus  occurred  among  the  wounded ;  and  this 
man  alone  recovered,  resection  of  his  elbow  having  been  performed. — London 
Medical  Record,  June  15,  1878. 

Gastrotomy. 

A  case  of  cancerous  ulceration  of  the  oesophagus,  in  which  it  was  found  neces- 
sary to  open  the  stomach,  is  reported  by  Dr.  Otto  Risel  of  Halle  in  the 
Deutsche  Medicinische  Wochenschrift,  of  May  4th.  The  patient  was  a  strong, 
well-nourished,  and  slightly  pale  man,  aged  fifty-two  years,  who  for  some  few  weeks 
before  he  came  under  the  author's  notice  had  suffered  from  difficulty  in  swallow- 
ing, and  complained  of  inability  to  pass  into  the  stomach  any  solid  food.  There 
had  not  been  any  vomiting  ;  the  patient  had  not  felt  any  pain,  but  had  been  much 
troubled  with  accumulation  of  mucus  in  the  throat.  The  seat  of  the  obstruc- 
tion in  the  gullet  was  referred  by  the  patient  to  a  point  behind  the  lower  portion 
of  the  sternum.  Behind  the  tendon  of  the  left  stern o- mastoid  muscle,  just  above 
the  corresponding  sterno-clavicular  articulation,  could  be  felt  a  firm,  immovable 


564 


Progress  of  the  Medical  Sciences. 


[Oct. 


tumour  of  about  the  size  of  a  pigeon's  egg.  This  was  smooth  over  its  anterior 
surface,  did  not  fluctuate,  and  was  not  painful.  The  oesophageal  sound  could  be 
passed  almost  as  far  as  the  stomach,  but  near  the  cardia  was  arrested  by  a  con- 
striction, through  which,  on  slight  pressure,  the  olivary  extremity  of  the  smallest 
tube  could  be  forced.  During  a  period  of  one  month  after  he  had  been  first  seen 
by  Dr.  Otto  Risel,  the  patient  derived  much  benefit  from  the  frequently  repeated 
introduction  of  the  oesophageal  sound.  There  was  diminishing  difficulty  in  swal- 
lowing, and  a  marked  increase  in  the  strength  and  general  condition.  After  this 
period,  however,  the  improvement  rapidly  ceased,  and  the  oesophageal  constric- 
tion increased  to  such  an  extent  as  to  prevent  the  introduction  into  the  stomach 
of  the  smallest  sound.  In  the  course  of  the  next  three  weeks  there  were  febrile 
paroxysms,  with  signs  of  infiltration  of  the  base  of  the  right  lung.  The  patient 
became  much  emaciated,  had  difficulty  in  swallowing  fluid  as  well  as  solid  food, 
and  was  much  troubled  by  a  violent  straining  cough,  with  much  expectoration  of 
thick  and  occasionally  blood-stained  mucus.  Attempts  at  passing  the  smallest 
sound  through  the  obstruction  in  the  gullet  caused  intense  pain.  There  was  dul- 
ness  over  the  back  of  the  chest  on  the  right  side,  and  crepitation,  fine  or  coarse, 
was  heard  over  all  parts  of  the  corresponding-  lung.  Hence  it  was  concluded  that 
there  had  been  perforation  of  the  oesophagus,  and  subsequent  outpouring  of  food 
into  a  paraesophageal  cavity  just  above  the  origin  of  the  diaphragm.  As  attempts 
to  feed  the  patient  by  the  rectum  were  attended  by  almost  negative  results,  gas- 
trotomy  was  performed  by  Dr.  Risel  on  November  9th  of  last  year.  An  incision 
having  been  made  under  carbolic  acid  spray  in  the  anterior  abdominal  wall,  the 
anterior  surface  of  the  stomach  was  found  without  much  difficulty,  and  then,  after 
having  been  dragged  forwards,  was  incised  and  fixed  to  the  edges  of  the  external 
wound.  Near  the  cardiac  region  of  the  organ  was  found  a  small,  hard,  tubercu- 
lated  tumour,  which  was  regarded  as  a  cancerous  gland.  In  consequence  of  the 
frequent  and  violent  fits  of  coughing,  no  attempt  was  made  to  pass  food  into  the 
stomach  until  the  third  day.  On  the  seventh  day,  the  patient  died  from  ex- 
haustion, in  a  state  of  collapse.  At  the  necropsy,  the  edges  of  the  gastric  and 
external  orifices  were  found,  to  be  firmly  glued  together.  Beyond  this  region 
there  were  no  traces  of  peritonitis.  At  the  posterior  portion  of  the  base  of  the 
right  lung  was  a  small  cavity  communicating  with  a  dilated  bronchus,  and  con- 
taining a  brownish  semi-fluid  mass.  The  lower  half  of  the  wall  of  the  oesophagus 
presented  a  large  ulcer  commencing  about  two  centimetres  above  the  cardiac 
extremity  of  the  stomach,  and  extending  upwards  over  an  extent  of  about  nine 
centimetres.  The  edges  of  this  ulcer  were  hard,  notched,  and  elevated,  its  base 
was  gray  and  sloughy,  and  in  its  midst  was  a  large  orifice  communicating  with 
the  above-mentioned  cavity  at  the  base  of  the  right  lung,  the  surface  of  which 
organ  in  this  region  was  closely  adherent  to  the  right  wall  of  the  oesophagus  and 
to  the  vertebral  column. 

Dr.  Risel,  in  his  remarks  on  this  case,  points  out  that,  as  was  proved  beyond 
doubt  by  the  necropsy,  death  was  the  result  of  exhaustion  and  not  of  the  opera- 
tion. The  peritonitis  had  been  purely  adhesive  and  limited  to  the  immediate 
neighbourhood  of  the  wound.  The  adhesions  between  the  margins  of  the  gastric 
and  those  of  the  external  wound  were  firm  and  had  not  been  disturbed  by  the 
violent  fits  of  coughing.  In  seeking  for  the  stomach  through  the  wound  in  the 
abdominal  wall,  the  best  guide,  it  is  stated,  is  the  under  surface  of  the  liver,  and 
the  hollow  viscus  may  be  readily  recognized  by  the  thickness  of  its  coat,  the 
absence  of  longitudinal  bands  of  muscle,  and  the  arrangement  of  its  vessels,  the 
veins  being  much  more  conspicuous  than  the  arteries,  along  the  greater  and  lesser 
curvatures.  In  cases  where  it  is  required  to  open  the  stomach  as  near  as  possible 
to  the  centre  of  its  long  axis,  the  best  external  incision  is  one  made  parallel  and 


1878.] 


Surgery. 


565 


about  a  finger's  breadth  internal  to  the  margin  of  the  left  osseous  wall  of  the 
thorax.  When  the  organ  has  to  be  opened  near  its  pyloric  extremity,  the 
incision  in  the  abdominal  wall  should  be  made  nearer  to  the  middle  line. — London 
Med.  Record,  June  15,  1878. 

Cholecystotomy  in  Dropsy  of  the  Gall-Bladder. 

Since  Mr.  Maunder  recommended  this  operation  in  cases  of  impacted  gall- 
stones (Laria  t,  vol.  ii.,  1876,  p.  640),  at  a  meeting  of  the  Clinical  Society,  when 
the  feasibility  of  such  a  procedure  was  discussed  in  relation  to  a  case  that  had 
been  under  Dr.  Daly's  care,  no  operator  has  been  found  bold  enough  to  carry  out 
the  suggestion  until  last  April,  when  Dr.  J.  Marion  Sims  (British  Medical 
Journal,  June,  18  78,  p.  811)  operated  upon  an  American  lady,  aged  45,  with 
great  enlargement  of  the  gall-bladder,  from  which  nearly  thirty  ounces  of  fluid 
was  removed,  together  with  sixty  gall-stones. 

The  operation  lasted  one  hour  and  sixteen  minutes.  The  most  tedious  part 
was  securing  the  cyst  in  the  incision  and  closing  up  the  wound.  She  lived  eight 
days.  The  operation  was  conducted  under  Lister's  process.  A  post-mortem 
examination  revealed  no  trace  of  peritonitis,  the  gall-bladder  was  firmly  adherent 
to  the  abdominal  walls,  and  contained  sixteen  gall-stones,  which,  being  saccu- 
lated, had  prevented  them  from  being  removed  during  life.  Although  the  case 
terminated  fatally,  from  the  poisonous  effects  of  absorbed  biliary  salts,  still  Dr. 
Sims  regarded  it  as  a  triumph  for  Listerism;  and  the  immediate  benefit  of  the 
operation  was  shown  in  the  relief  of  pain,  itching,  nausea,  vomiting,  and  in  the 
production  of  natural  stools. 

The  fluid  contained  in  the  distended  gall-bladder  was  proved,  by  analysis,  not 
to  be  either  bile  or  altered  bile,  but  a  sero-mueous  liquid,  secreted  by  the  mucous 
glands  and  epithelial  covering. — London  Med.  Record,  July  15,  1878. 

Enterostomy. 

In  the  Bulletin  Central  de  Lherapeutiqve,  May  30th,  M.  SuRMAY  has  an 
extensive  and  interesting  article  in  which,  starting  with  the  statement  of  the  well- 
known  facts  relating  to  deaths  from  inanition  in  cases  of  pyloric  closure,  and  the 
very  limited  efficacy  of  rectal  and  subcutaneous  alimentation,  he  questions 
whether  it  is  not  possible  to  act  upon  the  small  intestine  just  as  upon  the  stomach 
when  the  cardiac  extremity  is  closed  ;  if,  in  other  words,  "  enterostomy  may  not 
in  certain  cases  render  the  same  service  as  gastrostomy."  He  enters  at  length 
upon  the  consideration  of  the  involved  double  problem  of  physiology  and  surgery  : 
1,  "Will  the  intestinal  digestion  suffice  for  the  elaboration  of  alimentary  sub- 
stances, in  such  manner  as  to  render  them  assimilable  and  nutritive  without  the 
direct  intervention  of  the  stomach  ? ' '  and  2,  "Is  it  possible  to  make  and  maintain 
at  a  convenient  point  in  the  small  intestine  an  opening  through  which  may  be  in- 
troduced certain  appropriate  substances,  that  afterwards  shall  undergo  the  changes 
necessary  to  render  them  assimilable  and  contributive  to  nutrition?"  He  holds 
that  all  the  chemical  changes  required  in  food  to  render  it  absorbable  are  effected 
in  the  intestine,  and  that  but  a  single  one  of  them  commences  in  the  stomach,  and 
that  the  suppression  of  the  gastric  action  does  not  very  seriously  affect  nutrition 
(as  indicative  of  which  he  cites  the  case  of  sphacelation  of  the  entire  mucous 
membrane  of  the  stomach  with  almost  complete  integrity  of  the  digestive  organs, 
reported  by  Dujardin-Beaumetz),  while  it  is  altogether  otherwise  if  the  intestinal 
action  be  wanting,  as  has  been  shown  in  certain  reported  cases  of  artificial  anus 
high  up  ;  and  he  believes  that  the  first  question  can  be  answered  in  the  affirma- 
tive, provided  that  proper  means  are  adopted  to  prevent  the  escape,  through  the 


Progress  of  the  Medical  Sciences. 


[Oct. 


opening  made,  of  the  biliary  and  pancreatic  fluids ;  such  means  being  the  mainte- 
nance of  the  dorsal  decubitus  during  digestion,  and,  if  necessary,  the  use  of  a  cup 
or  India-rubber  bag  to  catch  the  escaping  liquids  which  can  later  be  returned  into 
the  bowel.  In  opening  the  small  intestine,  the  following  procedure  is  recom- 
mended : — 

On  a  line  about  a  third  of  an  inch  internal  to  the  anterior  extremity  of  the  ninth 
rib  of  the  left  side,  a  vertical  incision  from  2  to  2\  inches  long  is  to  be  made  in 
such  a  manner  as  that  its  central  point  shall  correspond  to  the  ninth  rib.  The 
skin,  the  superficial  fascia,  the  external  oblique,  the  internal  oblique,  and  the 
transversalis  muscles,  and  the  transversalis  fascia,  are  to  be  successively  divided, 
and  the  peritoneum  opened,  with  the  usual  precautions.  The  omentum  being 
turned  out  of  the  way,  and  "  the  intestinal  mass  uncovered,  the  transverse  colon, 
which  is  at  the  upper  end  of  the  incision,  may  be  easily  recognized,  and  very 
readily  distinguished  by  its  direction,  by  its  colour,  whiter  than  that  of  the  small 
intestine,  by  its  bands  and  constrietions,  and,  finally,  by  its  relations  with  the 
omentum.  Immediately  below  are  the  aggregated  coils  of  the  small  intestine. 
Between  these  coils  and  the  transverse  colon,  the  index  finger  is  to  be  carried 
directly  down  and  pushed  on  until  it  meets  the  spinal  column.  The  left  extremity 
of  the  pancreas  can  then  be  felt,  and  immediately  to  the  left  of  this  extremity 
and,  as  it  were,  connected  with  it,  an  intestine,  the  direction  of  which  is  trans- 
verse. This  intestine  is  to  be  hooked  up  with  the  curved  index  finger  and  drawn 
out.  If  it  be  perceived  that  it  yields  on  one  side,  but  remains  firmly  attached  on 
the  other,  it  is  the  jejunum  at  its  origin.  If,  on  the  contrary,  it  can  be  equally 
well  drawn  up  on  both  sides,  it  is  a  part  of  the  canal  further  down,  and  must  be 
let  go,  in  order  to  search  again.  Most  usually  we  come  after  the  first  stroke 
(coup)  upon  the  part  sought  for,  but  if  Ave  fail  it  is  not  difficult,  nor  does  it  re- 
quire any  great  length  of  time,  to  find  it.  Once  seized,  it  is  to  be  brought  up 
between  the  lips  of  the  wound  in  the  skin  and  fixed  there  by  a  sufficient  number 
of  points  of  the  interrupted  suture.  This  done,  the  intestine  can  be  opened  and 
appropriate  alimentary  substances  introduced."  The  author  in  a  foot-note  says 
that  he  has  selected  the  first  part  of  the  jejunum  in  which  to  make  the  opening, 
because  it  can  be  easily  found  by  following  the  method  indicated ;  while,  if  the 
incision  be  made  in  any  other  part  of  the  abdominal  wall,  we  have  no  certain 
means  of  knowing  what  part  of  the  small  intestine  has  been  opened.  Enterostomy 
then,  being  in  a  surgical  point  of  view  an  operation  perfectly  according  to  rule, 
and  physiologically  considered  a  rational  one,  should,  according  to  M.  Surmay, 
be  regarded  as  the  proper  one  in  those  cases  in  which  there  is  no  cachexia  nor 
hemorrhage,  no  threatened  perforation  nor  peritonitis,  where  the  real  cause  of 
the  impending  death  is  inanition  consequent  upon  impassable  constriction  of  the 
pylorus,  or,  the  pylorus  being  open,  upon  absolutely  uncontrollable  vomitings  due 
to  nervous  disturbance  or  even  to  simple  ulceration  of  the  gastric  mucous  mem- 
brane. Though  enterostomy  has  never  been  performed  upon  the  living  human 
subject,  and  will  remain  an  operation  of  altogether  exceptional  rarity,  M.  Surmay 
hopes  that  he  has  done  something  useful  if  he  has  been  able  to  show  that  it  is 
rational,  easy  of  execution,  and,  to  all  appearances,  capable  of  practical  applica- 
tion.— London  Med.  Record,  August  15,  1878. 

Foreign  Body  iu  the  Sigmoid  Flexure:  Successful  Removal. 
A  rare  and  curious  case  is  related  by  Dr.  Studsgaard  of  the  Communal  Hos- 
pital in  Copenhagen,  in  a  recent  number  of  the  Hosjntals-Tidende.  A  man. 
aged  35,  introduced  into  the  rectum,  with  the  open  end  uppermost,  a  preserve- 
bottle  nearly  seven  inches  long,  for  the  purpose  of  stopping  a  diarrhoea.  The 
next  morning  he  complained  of  pain  in  the  abdomen  ;  chloroform  was  given,  and 


1878.] 


Surgery. 


567 


the  bottle,  which  could  before  this  be  felt  in  the  rectum,  passed  higher  up,  and 
he  was  brought  to  the  hospital  (January  10th).  The  bottle  could  be  felt  through 
the  abdominal  wall,  lying  in  the  middle  line,  with  the  bottom  close  to  the  hori- 
zontal ramus  of  the  pubic  bone.  In  the  afternoon  he  was  deeply  narcotized,  and 
posterior  linear  rectotomy  was  performed,  and  an  attempt  was  made  to  reach  the 
bottle,  but  without  success.  Abdominal  section  was  therefore  performed,  under 
antiseptic  precautions,  in  the  linea  alba.  An  incision  having  been  carried  four 
inches  downwards  from  the  umbilicus,  a  loop  of  intestine,  apparently  a  portion  of 
the  sigmoid  flexure;  was  protruded  with  the  neck  of  the  bottle.  The  bowel  was 
then  divided  over  the  mouth  of  the  bottle  and  a  little  way  down  the  neck,  and 
removal  was  effected  slowly.  The  neighbouring  parts  were  protected  by  sponges 
and  compresses  from  the  escape  of  feces  ;  and,  after  the  bowel  had  been  cleaned, 
twelve  or  fourteen  catgut  sutures  were  applied  to  it,  each  being,  for  safety,  tied 
with  three  knots.  The  bowel  having  been  replaced,  the  wound  in  the  abdominal 
wall  was  united  by  eight  silk  sutures.  The  operation  lasted  an  hour.  Recovery 
was  slow,  and  the  prognosis  was  for  a  time  doubtful  in  consequence  of  local  peri- 
tonitis and  the  formation  of  abscesses,  which  opened  partly  through  the  incision 
in  the  abdominal  wall  and  partly  through  the  rectum  ;  the  patient  was,  however, 
discharged  quite  cured  on  April  16th — less  than  fourteen  weeks  after  the  operation. 
The  bottle  was  17  centimetres  (6.8  inches)  long,  5  centimetres  (2  inches)  in 
diameter  at  the  lower  end,  and  3  centimetres  (1.2  inches)  at  the  upper  end.  In 
commenting  on  this  case,  Dr.  Studsgaard  refers  to  three  others  of  a  similar 
character  ;  one  related  by  Ogle,  in  which  recovery  followed  spontaneous  discharge 
of  the  foreign  body  (a  stick)  ;  one  by  Closmadeuc,  where  the  patient  died  of 
peritonitis,  without  operation  ;  and  one  in  which  laparo-enterotomy  was  success- 
fully performed  in  1849  by  Reali  of  Orvieto. — Brit.  Med.  Journal,  August  3, 
1878. 

Treatment  of  Hydrocele  by  Incision  performed  Antiseptic  ally. 

Dr.  Genzmee  (Volkmann's  Klinischer  Vortrage,  No.  135)  gives  a  list  of 
sixty-nine  cases  treated  in  this  way  without  a  single  fatal  result,  and  with  no  ex- 
cessive inflammation.  The  average  duration  of  the  stay  of  patients  in  the  hos- 
pital was  ten  days.  There  was  in  but  one  or  two  cases  an  elevation  of  tempera- 
ture of  more  than  three  degrees.  The  method  is  to  open  the  sac  by  an  incision 
from  three  to  four  inches  in  length.  The  testicle  is  then  examined,  and  if  there 
be  cheesy  orchitis  the  diseased  portions  are  laid  open  and  scraped  out.  The 
edges  of  the  tunica  are  then  stitched  to  the  scrotum  with  catgut  sutures.  The 
testicle  now  appears  lying  at  the  bottom  of  a  gaping  wound.  A  drainage-tube  is 
placed  vertically  upon  the  organ,  and  the  edges  of  the  wound  are  partly  approxi- 
mated by  one  or  two  deep  silk  sutures  to  prevent  the  testicle  from  escaping  from 
the  sac.  Primary  union  of  the  walls  of  the  sac  takes  place,  and  a  slight  granu- 
lating surface  is  left  at  the  end  of  a  few  days  to  mark  the  site  of  the  cut.  The 
tube  is  removed  usually  about  the  fourth  day,  when  the  silk  sutures  are  also 
taken  out,  and  the  dressing  changed  a  second  time  at  the  end  of  a  week.  The 
wound  is  then  dressed  with  benzoated  cotton-batting  inside  of  a  suspension  band- 
age, and  the  patient  discharged. — London  Med.  Record,  Aug.  15,  1878. 

Ergotin  in  Diseases  of  the  Bladder. 

Dr.  Molfese,  in  the  Girillo  of  May  5,  1878,  calls  attention  to  the  results  of 
the  internal  use  of  ergotin  in  cases  of  paralysis  of  the  bladder,  hemorrhage,  etc. 
He  relates  three  cases.  In  the  first,  a  priest  aged  86  was  suddenly  attacked  with 
retention  of  urine.    After  this  condition  had  lasted  3  6  hours,  the  urine  was  drawn 


568 


Progress  of  the  Medical  Sciences. 


[Oct. 


off  by  a  catheter ;  it  was  turbid  and  contained  mucus  and  pus,  and,  eight  days 
later,  blood  in  large  quantity.  Injections  of  alum,  nitrate  of  silver,  and  sulphate 
of  zinc  produced  no  effect.  Dr.  Molfese  then  ordered  a  spoonful  of  the  follow- 
ing mixture  every  half  hour:  Bonjean's  ergotin  1  gramme,  water  100  grammes, 
syrup  of  orange  peel  50  grammes.  Injections  of  a  very  dilute  solution  of  salicylic 
acid  were  also  given.  In  eight  days  the  blood  had  completely  disappeared  from 
the  urine.  The  catheter  was  used  for  some  days,  and  after  treatment  for  a  month 
the  patient  was  cured.  In  the  second  case,  a  man  aged  72  had  retention  of  urine, 
which  contained  mucus,  pus,  and  blood.  After  the  use  of  ergotin  for  20  days, 
the  bladder  regained  its  power.  The  third  case  was  that  of  a  man  aged  51,  who 
had  twice  suffered  from  gonorrhoea,  specific  ulcer,  and  suppurating  bubo.  For 
two  months,  he  had  been  unable  to  retain  his  urine.  After  the  use  of  ergotin  for 
ten  days,  the  incontinence  had  nearly  disappeared ;  and,  at  the  end  of  fourteen 
days,  the  patient  was  cured. — London  Med.  Record,  Aug.  15,  1878. 

Syphilitic  Stricture  of  tJte  Rectum;  Rectotomy  hy  a  new  Operation. 
In  a  clinical  lecture  reported  in  Le  Progres  Me'dical,  June  22,  1878,  M.  Tre- 
lat  relates  the  particulars  of  a  case  in  which  he  practised  division  of  a  stricture 
of  the  rectum. 

The  patient  was  a  woman  (age  not  mentioned)  who  had  been  operated  on  by 
M.  Trelat  in  1873.  The  exact  nature  of  the  operation  then  performed  could  not 
be  ascertained,  as  the  notes  had  been  lost,  but  she  had  been  completely  relieved 
at  that  time.  Towards  the  end  of  187  7  the  patient  began  to  suffer  from  pain  in 
defecation,  together  with  a  glairy  yellow  bloody  discharge  from  the  anus.  Five 
months  ago,  feces  began  to  escape  from  an  opening  at  the  lower  and  back  part  of 
the  vulva,  which  induced  the  patient  to  apply  at  the  hospital  for  relief.  On  ad- 
mission, the  woman  denied  syphilis,  but  had  the  remains  of  a  syphilitic  rash,  and 
had  been  taking  syphilitic  remedies  under  the  direction  of  her  medical  attendant. 
On  examination,  the  anus  was  found  smeared  with  fecal  matter,  and  a  bloody 
purulent  discharge.  Around  the  orifice  were  scattered  elevated  patches,  and 
from  the  base  of  one  of  these  ran  a  fistula,  which  communicated  with  the  anal 
aperture  by  a  short  wide  track.  Other  sinuses  existed  in  the  neighbourhood. 
Digital  examination  revealed  the  existence  of  a  certain  amount  of  contractile 
power  of  the  sphincter.  In  the  anterior  wall  of  the  rectum  was  a  deeply  depressed 
softened  spot,  in  the  centre  of  which  was  the  orifice  of  a  fistula,  which  ran  towards 
the  vulva.  Behind,  the  tissues  were  softened  and  ulcerated.  Above  these  was 
the  stricture,  and,  above  this  again,  thickening  of  the  bowel  extended  higher  up. 
The  walls  of  the  lower  part  of  the  rectum  were  thickened  and  traversed  by  fistula. 
After  general  antisyphilitic  treatment  and  the  local  application  of  glycerine  of 
starch,  with  rhatany  and  catechu,  for  three  weeks,  improvement  had  taken  place. 
This,  however,  proved  to  be  only  temporary,  and  a  month  and  a  half  after  the 
commencement  of  treatment  the  following  operation  was  performed.  A  solid 
steel  rod,  having  at  its  end  a  movable  and  sharp  pointed  kind  of  needle  or  shuttle 
(navette),  carrying  a  thread,  was  thrust  upwards,  parallel  to  and  behind  the  rec- 
tum for  a  distance  of  about  31  inches  above  the  anus.  By  a  slight  see-saw  move- 
ment of  the  handle  of  the  instrument,  the  point  was  now  made  to  perforate  the 
wall  of  the  rectum,  and  the  needle  was  thus  carried  into  the  rectal  cavity  above 
the  stricture.  Another  steel  rod,  the  end  of  which  terminated  in  a  frame,  over 
which  a  layer  of  caoutchouc  was  stretched  (very  like  a  laryngoscope  of  which  the 
mirror  has  been  replaced  by  an  elastic  membrane),  was  next  introduced  up  the 
rectum  through  the  anus,  and  the  point  of  the  needle  was  then  firmly  fixed  from 
below  upwards  in  the  caoutchouc.    The  rectal  rod  was  now  withdrawn,  tog-ether 


1878.] 


Surgery. 


569 


with  the  needle  and  thread.  The  posterior  wall  of  the  rectum,  to  a  point  above 
the  stricture,  was  thus  included  in  the  loop.  The  thread  was  then  replaced  by 
the  wire  of  the  galvano-cautery.  and  division  effected  without  the  least  loss  of 
blood.  The  operation  was  performed  on  April  19.  On  the  28th  the  patient  was 
attacked  by  pneumonia,  very  soon  complicated  with  erysipelas  of  the  face,  the 
starting  point  of  which  was  a  large  specific  ulceration  of  the  nasal  fossa?.  Death 
occurred  on  May  8,  without  any  local  accident  having  followed  the  operation  on 
the  rectum. 

M.  Trelat  remarks  that  the  above  was  evidently  a  case  of  the  affection  described 
by  Guerin,  Verneuil,  Fournier,  and  himself  as  tertiary  syphilitic  affection  of  the 
anus  and  rectum,  or  ano-rectal  syphiloma.  The  disease  is  caused  by  a  syphilitic 
neoplasm  of  a  special  nature  and  different  from  gumma.  The  existence  of  multi- 
ple fistula  is  significative,  and  their  appearance  is  characteristic  of  their  origin. 
They  are  perfectly  dry,  and  do  not  furnish  any  discharge.  The  fistulous  track 
cicatrizes  almost  as  soon  as  it  is  formed.  It  is  often  very  short,  and  has  then  a 
punched-out  appearance.  The  fistula?  affect  the  portion  of  the  rectum  below  the 
stricture. 

With  regard  to  the  effects  of  medication,  M.  Tr£lat  differs  from  Fournier,  who 
thinks  specific  treatment  useful  only  at  an  early  stage.  In  two  of  Iff.  Trelat's 
cases,  the  affection  was  already  of  old  standing,  but,  under  mercury  and  iodide  of 
potassium  internally,  with  the  local  application  of  glycerine,  diminution  of  the 
neoplasm,  desiccation  of  the  fistula?,  and  disappearance  of  pain  took  place,  and 
these  good  results  have  been  obtained. — London  Med.  Record,  Aug.  15,  1878. 

Dupuytren's  Contraction  of  the  Fingers. 

Mr.  "William  Adams  contributes  to  the  British  Medical  Journal,  June,  18  78, 
p.  928,  a  paper  upon  this  disease,  illustrated  with  plates  of  the  dissected  parts. 
Mr.  Adams  has  never  met  with  a  case  in  the  female,  and  generally  has  found  it 
to  attack  men  in  the  middle,  or  beyond  the  middle,  period  of  life. 

The  pathology  and  treatment  of  this  form  of  finger  contraction  is  still  the  sub- 
ject of  much  difference  of  opinion,  and  Dupuytren  appears  to  have  been  the  first 
to  investigate  its  anatomical  condition  by  dissection.  He  found,  the  skin  being 
removed  from  the  whole  extent  of  the  palm  of  the  hand,  and  the  palmar  fascia 
of  the  fingers,  that  the  fold,  or  the  puckering  of  this  structure,  entirely  disap- 
peared. The  palmar  aponeurosis  was  found  retracted  and  diminished  in  length, 
its  inferior  part  being  divided  into  cords,  which  passed  on  to  the  sides  of  the 
affected  fingers.  On  extending  the  finger,  he  observed  that  the  aponeurosis  un- 
derwent a  kind  of  tension  of  crispation — this  was  a  ray  of  light ;  so  he  consid- 
ered the  aponeurosis  to  be  the  cause  of  the  disease.  He  cut  the  prolongations  on 
the  sides  of  the  fingers,  and  immediately  the  contractions  ceased,  and  the  fingers 
were  readily  completely  extended,  the  tendons  being  natural ;  the  sheaths  were 
not  opened  ;  the  articulations,  ligaments,  and  bones  were  in  their  natural  state. 

In  one  case  of  the  affection  that  fell  under  Mr.  Adams's  care,  a  gentleman, 
suffering  from  Dupuytren's  contraction  of  the  fourth  and  fifth  fingers  of  the  right 
hand,  while  trying  to  hold  a  restive  horse,  had  them  torn  open  and  the  skin  of 
the  palm  torn  across,  together  with  the  palmar  fascia the  sheaths  of  the  tendons 
were  not  injured.  The  hand  was  bandaged  with  the  fingers  extended,  and 
quickly  healed,  with  the  flexion  power  of  the  fingers  perfect.  Mr.  Adams 
thinks  that  the  affection  depends  nearly  always  upon  a  constitutional  rather  than 
a  local  cause,  and  essentially  upon  a  gouty  diathesis. 

By  means  of  a  very  small  tenotomy  knife.  Mr.  Adams  makes  multiple  subcu- 
taneous divisions  of  the  palmar  fascia,  cutting  downwards  very  slowly  and  cau- 


570 


Progress  of  the  Medical  Sciences. 


[Oct. 


tiously,  taking  care  not  to  clip  the  point  of  the  scalpel,  or  to  divide  any  structures 
except  the  contracted  band  of  fascia.  In  many  cases,  four  punctures  are  suffi- 
cient for  two  fingers;  if  there  be  more  than  two  to  operate  upon,  it  is  better  to 
confine  the  operation  to  two  fingers.  The  fingers  are  immediately  extended  and 
retained  by  splints.  The  operation  is  readily  performed  under  ether-spray,  if  the 
frozen  skin  be  rapidly  thawed  by  friction  with  the  operator's  warm  hand,  so  as 
to  leave  the  deeper  parts  insensible  to  pain. — London  Med,  Record,  Aug.  15, 
1878. 

Sequel  to  a  Case  of  Aneurism  of  the  Aorta,  and  the  Innominate,  Subclavian, 
and  Carotid  Arteries,  treated  by  the  Double  Distal  Ligature. 

Mr.  Richard  Barwell  reported  to  the  Royal  Medical  and  Chirurgical  So- 
ciety (British  Med.  Journ.,  June  8,  1878)  the  sequel  to  the  case  which  was 
exhibited  to  the  Society  in  November  last  (see  the  American  Journal  of  the 
Medical  Sciences  for  April,  1878,  p.  275). 

On  November  14,  the  patient  left  the  hospital.  On  the  20th,  he  came  to  the 
hospital  on  formal  business ;  and,  as  he  was  suffering  from  bronchitis,  Mr.  Bar- 
well  persuaded  him  to  remain.  He  was  very  intractable,  and,  not  being  allowed 
brandy,  left  on  the  22d.  He  walked  home  (about  two  miles)  very  thinly  clad, 
through  snow  and  sleet,  sat  four  hours  in  wet  clothes  without  a  fire,  became 
rapidly  worse,  and  died  on  November  24.  On  November  25,  a  post-mortem 
examination  was  made.  The  aneurism,  which  appeared  solid,  was  removed, 
together  with  the  heart  and  great  vessels.  No  other  disease  was  discoverable, 
except  very  acute  bronchitis  (muco-pus  in  the  large  and  small  bronchi),  hypo- 
static pneumonia,  and  oedema  of  the  lungs.  The  blood  in  the  arterial  system  was 
dark,  like  that  of  the  veins.  The  aneurismal  tumour,  rather  larger  than  a  tennis- 
ball,  sprang  from  the  junction  of  the  first  and  second  parts  of  the  aorta.  Its 
pressure  had  altered  the  course  and  relations  of  the  trachea  and  oesophagus ;  the 
large  veins  also  were  peculiar.  It  was  remarkably  hard  and  firm.  At  its  upper 
part,  it  was  elongated  into  a  subsidiary  enlargement,  which  lay  in  the  neck,  and 
was  in  front  divided  from  the  rest  of  the  aneurism  by  a  groove  marked  in  it  by 
the  clavicle.  The  back  of  the  sac  was  moulded  in  the  apex  of  the  lung.  The 
sac  was  laid  open  from  behind  forward.  There  was  within  it,  still  persistent,  a 
globular  cavity,  perhaps  an  inch  in  diameter;  this  was  surrounded  by  a  very  firm 
clot  of  variable  thickness  ;  and  in  front,  close  to  its  opening  into  the  aorta,  it  was 
rather  more  than  one-third  of  an  inch  thick  ;  behind,  an  inch  and  a  half.  The 
subsidiary  tumour  was  quite  obliterated,  so  that  here  the  clot  Avas  more  than  two 
inches  thick.  No  vessel  opened  out  of  the  aneurism  ;  the  innominate  being,  like 
the  right  subclavian  and  carotid,  obliterated.  The  left  vessels  came  off  from  the 
aorta  itself  below  the  mouth  of  the  aneurism.  The  specimen  showed  that  the 
tumour  had  greatly  shrunk  since  the  operation ;  that  the  whole  tumour  was  as 
much  filled  as  could  be  expected  in  the  time ;  that,  had  the  man  chosen  to  re- 
main in  the  hospital,  or  been  moderately  prudent,  the  whole  cavity  must  almost 
of  necessity  have  become  obliterated,  since  the  aneurism,  thickened  by  hard  clot, 
could  neither  have  enlarged  nor  burst ;  and,  since  there  was  no  thoroughfare 
within  the  sac,  there  could  have  been  no  blood-stream  through  it.  In  fact, 
though  the  man,  by  his  own  perversity,  contracted  an  intercurrent  fatal  disease, 
the  aneurism  was  to  all  intents  and  purposes  cured. 

Reunion  and  Restoration  of  Divided  Nerves. 
Mr.  Wheelhouse,  in  his  recent  address  on  Surgery  (British  Med.  Journal. 
Aug.  10,  1878),  made  the  following  remarks  on  this  interesting  subject:  — 
In  the  Lancet  of  June  1  of  the  present  year  (see  Monthly  Abstract  for  July. 


1878.] 


Surgery. 


571 


p.  314)  a  series  of  experiments  are  recorded  as  in  progress  in  Germany,  the  ob- 
ject of  which  is  to  ascertain  whether  the  nerves,  like  other  structures,  are  not 
amenable  to  surgical  treatment  for  their  restoration  after  division  and  complete 
loss  of  function ;  but,  whilst  the  Germans  are  patiently  experimenting  to  deter- 
mine the  point,  it  is  my  good  fortune  to  be  able  to  answer  this  question  distinctly 
In  the  affirmative,  as  the  following  case  will  show. 

On  May  5,  1875,  a  patient  named  Adam  Smith,  a  labourer,  aged  22,  entered 
the  Infirmary  at  Leeds,  under  my  care.  He  limped  into  the  ward  on  crutches, 
his  left  lower  limb  being  completely  paralyzed  and  useless,  and  stated  that  he 
had  come  to  request  us  to  remove  it,  as  an  incumbrance.  The  story  he  told  me 
concerning  it  was  tins.  Nine  months  previously,  as  he  was  returning  home  one 
evening,  at  the  close  of  his  day's  labour,  carrying  his  scythe  over  his  shoulder, 
being  anxious  to  make  a  short  cut  to  his  cottage,  he  attempted  to  climb  over  a 
fence  :  in  doing  this,  the  point  of  his  scythe  caught  in  the  hedge  behind  him ;  he 
was  jerked  suddenly  backward,  and  fell  with  the  back  of  his  thigh  upon  the  sharp 
edge  of  the  implement.  The  result  of  this  was  a  ghastly  wound,  the  contracted 
cicatrix  of  which  measured  nine  inches  in  length  when  I  first  saw  it  nine  months 
afterwards.  He  lay,  bleeding  profusely,  where  he  fell  for  many  hours  before  he 
w^s  found  and  carried  home  ;  there  the  hemorrhage  was  stanched,  the  wound 
was  dressed,  and,  in  process  of  time,  it  slowly  healed;  but  he  noticed,  during  the 
whole  time  so  occupied,  that  the  limb  was  slowly  wasting  and  withering'  away, 
and  that  it  manifested  no  sign  whatever  of  any  returning  sensibility. 

Eventually,  when  he  was  able  to  leave  his  bed,  he  found  to  his  horror  that, 
although  the  wound  was  healed  and  the  limbwas  apparently  saved,  it  had  become 
wholly  useless  to  him.  So  far  as  the  distribution  of  the  sciatic  nerve  was  con- 
cerned, the  power  of  sensation  was  entirely  lost;  of  voluntary  muscular  power  he 
had  none,  and  the  joints  were  relaxed  and  tlaccid. 

I  need  not  detail  to  you  all  the  efforts,  vain  efforts  indeed,  that  he  made  to 
recover  the  lost  powers  of  the  limb  ;  suffice  it  to  say  that,  receiving  no  benefit 
from  anything  he  did  or  tried,  he  finally  came  to  the  hospital  to  ask  for  its 
removal. 

The  whole  cause  of  the  mischief  was,  of  course,  clear  at  a  glance.  The  sciatic 
nerve  had  been  divided,  and,  in  the  healing  of  the  wound,  the  separated  ends 
had  never  reunited.  Here,  if  ever,  was  a  fair  opportunity  to  test  the  question  : 
Are  nerves  which  have  been  divided,  and  have  long  remained  disunited,  capable 
of  restoration  ? 

I  called  my  colleagues  to  my  assistance  in  forming  an  opinion  on  the  matter. 
Dr.  Clifford  Allbut  was  good  enough  most  patiently  and  carefully  to  test  elec- 
trically the  condition  of  the  disused  and  wasted  muscles,  and  he  reported  that, 
though  not  wholly  destroyed,  their  irritability  was  well  nigh  exhausted.  My 
surgical  colleagues  agreed  with*  me  that  whereas,  should  the  attempt  to  restore 
the  lost  nerve-power  altogether  fail,  I  could  still,  as  a  last  resource,  remove  the 
limb,  I  should  be  justified  in  making  an  attempt  to  reunite  the  ends  of  the 
divided  nerve.  After  fully  explaining  to  the  patient  the  position  of  affairs,  and 
obtaining  his  assent,  I  determined  to  do  so. 

Having  laid  open  the  back  of  the  thigh,  and,  by  a  careful  and  deliberate  dis- 
section of  the  parts,  exposed  the  wounded  nerve,  I  found  it  completely  cut  across  ; 
the  two  ends  were  firmly  felted  in  cicatricial  tissue  two  inches  apart.  On  the 
upper  end  was  a  large  bulbous  swelling,  the  lower  appeared  atrophied  and  some- 
what wasted.  Both  were  carefully  loosened  and  detached  ;  the  bulb  was  removed 
from  the  upper  one,  and  each  was  then  pared  obliquely  until  apparently  fresh 
nerve-tissue  was  exposed.  When  I  then  attempted  to  bring  them  together,  the 
nerve  was  found  to  be  so  much  shortened  that  I  could  not  do  so  until  I  flexed  the 


572 


Progress  of  the  Medical  Sciences. 


[Oct. 


knee  fully.  This  enabled  me  to  make  the  ends  of  the  nerve  meet  without  strain ; 
they  were  then  carefully  stitched  together  with  very  fine  carbolized  catgut  thread, 
the  wound  was  closed,  the  ankle  was  firmly  lashed  to  the  buttock,  and  in  this 
position  the  patient  was  put  to  bed. 

I  will  not  weary  you  with  details.  Suffice  it  to  say  that  little  by  little,  and  in 
very  wandering  fashion,  day  by  day,  and  week  after  week,  sensation  was  found 
to  be  returning  in  the  limb.  At  the  end  of  five  weeks,  I  began  slowly  to  relax 
the  position  and  let  down  the  leg  inch  by  inch,  until  at  length  it  became  straight 
again,  and  then,  to  my  intense  satisfaction,  I  found  that  the  restored  sensibility 
remained.  By  very  slow  degrees,  the  power  of  voluntary  motion  also  returned, 
and,  on  August  7,  he  was  discharged  from  the  hospital  so  far  cured  that,  with 
the  help  of  two  sticks,  he  was  able  to  support  himself  on  the  limb,  and  could 
walk.  From  that  time  to  this,  he  has  gone  on  improving.  During  the  whole  of 
the  past  winter  he  has  worked  in  the  fields  as  he  was  wont  to  do  before  his  acci- 
dent, requiring  neither  stick  nor  support,  nor  help  of  any  kind ;  and,  though  the 
limb  remains  greatly  inferior  in  size  and  nutrition  to  the  opposite  one,  it  is,  to  all 
intents  and  purposes,  a  useful  member  again. 

Since  the  performance  of  that  operation,  my  colleague,  Mr.  Atkinson,  has  in 
similar  manner  successfully  reunited  a  divided  median,  and  Mr.  Jessop  has  re- 
minded me  that,  long  prior  to  my  case,  he  also  had  been  equally  happy  in  thus 
dealing  with  an  ulnar  nerve. 

Severe  Injury  of  the  Axilla  during  Reduction  of  a  Dislocated  Humerus. 

Mr.  Thomas  Smith,  in  the  Lancet,  July,  1878,  p.  3,  reports  a  case  where,  with 
the  heel  in  the  axilla  and  from  a  force  not  greater  than  that  usually  employed, 
the  axilla  tore  as  though  it  had  been  wet  paper,  the  foot  apparently  cutting  its 
way  through  the  tissues  and  not  tearing  them  by  excessive  stretching.  The  pa- 
tient was  a  cellarman,  aged  58,  who  had  eight  weeks  previously  fallen  on  his 
elbow  and  received  a  subglenoid  dislocation  of  the  humerus,  which,  however,  was 
not  detected  at  the  time.  He  died  nine  days  afterwards  from  exhaustion.  The 
pectoral  muscles  were  almost  completely  torn  across,  the  vessels  and  nerves  un- 
injured. 

On  2'>°st-mortem  examination,  diffuse  suppuration  was  found  to  exist  in  and 
around  the  axilla,  and  the  parts  about  the  upper  and  middle  lobes  of  the  right 
lung  were  in  a  state  of  consolidation.  The  heart  was  flabby  :  the  liver  large, 
pallid,  and  fatty  ;  the  kidneys  normal ;  the  spleen  large,  soft,  and  semifluid  ;  ves- 
sels of  the  size  of  the  tibials  were  rigid  from  calcareous  degeneration.  The  mus- 
cles generally  were  paler,  softer,  and  more  flabby  than  normal.  At  the  seat  of 
injury,  nothing  could  be  ascertained  as  to  their  condition  as  regards  degeneracy, 
owing  to  the  amount  of  sloughing  that  had  taken  place.  No  microscopical  ex- 
amination was  made. 

[This  case  is  one  of  very  great  rarity,  if  not  unique.  Several  instances  are 
recorded  in  which  injuries  of  the  axillary  vessels  and  nerves  have  occurred  in  the 
reduction  of  old  dislocations  of  the  humerus,  and  are  referred  to  by  Mr.  Erichsen 
in  the  Science  and  Art  of  Surgery ;  but  cases  of  such  extreme  friability  of  the  parts 
as  is  described  by  Mr.  Smith  are  apparently  unknown,  or  almost  so,  in  surgical 
literature.] — Lond.  Med.  Record,  Aug.  15,  1878. 

Arthritis  Secondary  to  Acute  Myelitis. 
The  occurrence  of  arthritic  changes  secondary  to  chronic  spinal  affections  is 
now  well  established,  but  instances  of  those  changes  as  the  result  of  such  acute 
affection  of  the  cord  as  give  rise  to  the  sloughing  of  the  tissues  have  very  rarely 


1878.] 


Surgery. 


573 


been  recorded.  Such  a  case  lias  been  described  by  M.  Vallin  in  a  recent  num- 
ber of  V  Union  Midicale.  Complete  paraplegia  came  on  in  the  course  of  two 
days  in  a  healthy  young  man,  accompanied  by  loss  of  sensibility  and  of  power 
over  the  sphincters,  death  occurring  at  the. end  of  two  months  in  consequence  of 
extensive  bedsores,  which  had  commenced  on  the  second  day  of  illness.  The 
initial  lesion  was  found  to  have  been  confined  to  the  gray  matter  and  posterior 
column.  Phlyctenules  had  formed  on  the  feet,  and  the  paralyzed  parts  were  the 
seat  of  a  hard  oedema  extending  as  high  as  the  loss  of  sensibility.  The  urine  was 
not  albuminous,  and  the  kidneys  were  healthy.  Effusion  into  both  knee-joints 
occurred  in  a  month  after  the  onset  of  the  paraplegia,  sufficient  to  elevate  the 
patella  from  the  condyles.  After  death  one  of  these  joints  was  found  to  contain 
about  two  ounces  of  purulent  dark-coloured  liquid.  The  synovial  membrane  was 
thickened,  infiltrated,  and  indurated,  and  its  fringes  were  opaque  and  purulent  in 
aspect.  The  cartilages  were  covered  by  flakes  of  pus.  The  inner  aspects  of  the 
condyles  of  the  tibia  and  femur  were  entirely  deprived  of  their  cartilage,  and  the 
denuded  bone  was  porous  and  friable.  The  other  knee-joint  only  contained  a 
quantity  of  lemon-coloured  liquid.  The  marrow  of  the  bone  in  the  vicinity  of  the 
joint  most  affected  had  undergone  fatty  change,  and  the  bony  tissue  presented  all 
the  signs  of  osteitis. 

It  is  probable  that  cases  similar  to  this  have  led  to  the  prevalence  of  the  opinion, 
which  is  very  common  among  French  authorities,  that  all  acute  affections  of  the 
spinal  cord  are  "rheumatic."  The  arthritic  changes  are  not  uncommonly  re- 
garded as  the  manifestation  of  acute  rheumatism,  when  they  are  really  secondary 
to  the  nervous  affection. — Lancet,  August  24,  1878. 

Dislocation  of  the  Muscles  and  their  Treatment. 
Mr.  Geo.  W.  Callender  (British  Medical  Journal,  July,  1878,  p.  51)  dis- 
cusses this  class  of  injuries,  which  are  far  from  being  rare,  and  yet  are  seldom 
alluded  to  in  surgical  works.  Slight  as  are  many  of  these  hurts,  in  a  surgical 
point  of  view,  still  they  so  seriously  interfere  with  the  comfort  of  the  patient,  and 
are  attended  with  so  much  chronic  pain,  as  to  make  their  diagnosis  and  treatment 
a  point  of  great  interest  to  all.  The  tendons  most  frequently  affected  are  that  of 
the  biceps  and  the  ligamentum  patellae.  Dislocation  of  the  biceps  tendon,  when 
the  sheaths  that  bind  it  in  its  groove  are  torn,  is  frequently  beyond  treatment,  as 
far  as  regards  cure.  The  leaders  of  the  wrist  are  often  great  sufferers,  and  it  is 
only  within  the  few  weeks  following  the  occurrence  of  the  accident  that  the  repair 
of  the  surrounding  tendinous  injuries  has  a  chance  of  being  perfected  by  prompt 
reduction  and  rest. 

A  most  troublesome  case  of  dislocation  of  the  two  peronei  from  behind  the  ex- 
ternal malleolus  fell  under  Mr.  Callender's  care.  It  had  occurred  two  years  pre- 
viously, and  could  only  be  relieved  by  instrumental  aid.  Rupture  of  the  muscular 
sheath,  causing  protrusion  of  the  exposed  muscle,  is  not  at  all  an  uncommon 
accident,  and  is  very  difficult  to  cure  radically. 

Dislocations  of  the  muscles  themselves  are  also  not  rarely  met  with,  causing 
great  misery  until  reduced,  attended  as  they  are  by  tearing  of  surrounding  parts, 
straining  of  nerve-fibres,  rupture  of  small  vessels,  and  pain  in  every  effort  of  the 
displaced  muscle.  A  man  carrying  a  heavy  box  down  stairs,  slipped  in  his  en- 
deavours to  recover  his  footing,  twisted  himself,  and,  at  once,  felt  a  severe  pain 
in  the  lower  dorsal  region  of  the  spine,  by  the  side  of  the  spinous  processes  ;  over 
the  painful  spot  a  slight  swelling  could  be  felt.  By  placing  the  patient  in  the 
position  that  caused  least  pain,  the  muscle  was  relaxed,  and  then,  pressure  with 
the  hand  armed  with  a  pad  of  lint,  and  the  patient  moving  so  as  to  bring  the  dis- 
placed muscle  into  play,  quickly  caused  reduction.    Rest  for  a  time  apparently 


574 


Progress  of  the  Medical  Sciences. 


[Oct. 


cured  him,  but  he  was  afterwards  subject  to  returns  of  the  displacement,  which 
he  learnt  to  reduce  himself.  Another  case  of  disloeation  of  the  pronator  radii 
teres,  whilst  playing  lawn  tennis,  fell  under  Mr.  Callender's  notice,  and  led  him 
to  study  the  subject  of  muscular  dislocation,  which  had  been  previously  discussed 
by  M.  Ponteau,  who  relates  an  interesting  instance  where  a  young  girl  dislocated 
one  or  more  of  the  digitations  of  the  splenitis.  If,  then,  we  meet  with  a  case  in 
which  sudden  and  unusual  movements  of  the  body  have  been  followed  by  pain — 
local  in  its  character — made  worse  by  certain  movements,  or  preventing  certain 
movements,  and  especially  if  such  pain  be  referred  to  the  site  of  muscular  digita- 
tions about  the  spine,  etc.,  it  is  wise  to  adopt  measures  to  reduce  muscular  dislo- 
cations, by  relaxing  the  muscles  or  part  of  muscle  displaced,  and  by  rubbing, 
kneading,  or  pressing,  while  attempting  to  reduce  it;  if  this  fail,  make  pressure 
over  the  part  while  the  muscle  is  brought  into  play.  As  we  need  guidance  from 
the  patient,  these  manipulations,  often  painful,  had  better  be  done  without  the 
aid  of  amesthetics. — London  Medical  Record,  Aug.  15,  1878. 

Muscular  Necrosis. 
Dr.  Lucr  e  (Strasburg)  related,  at  the  late  Congress  of  the  Society  of  German 
Surgeons,  the  case  of  a  medical  student,  who,  while  on  the  ice  on  February  10th, 
slipped  and  fell.  He  did  not  feel  any  special  pain,  and  no  extravasation  of  blood 
could  be  seen.  While  in  bed  on  the  evening  of  the  same  day,  he  was  attacked 
with  severe  pain  in  the  leg,  in  the  middle  of  which  a  small  swelling  of  the  size  of 
a  cherry  was  detected.  The  pain  became  so  severe  that  Dr.  Kohts  administered 
chloral,  injections  of  morphia,  ice,  etc.,  but  without  result.  On  February  13th, 
leeches  were  applied,  without  relief.  On  the  21st  Dr.  Liicke  saw  the  patient  for 
the  first  time.  The  whole  leg  appeared  swollen,  and  a  point  at  the  upper  part, 
between  the  bones,  was  very  painful,  and  projected  considerably.  Percussion 
showed  that  the  case  was  not  one  of  osteomyelitis  of  the  tibia  ;  the  fibula  was  in- 
accessible in  consequence  of  the  swelling  of  the  soft  parts.  An  incision  was  made, 
and  a  piece  of  muscle  in  a  state  of  waxy  degeneration  escaped,  but  no  pus,  al- 
though the  tibia  was  partly  denuded  of  periosteum.  The  operation  was  done 
under  antiseptic  precautions.  On  February  23d  the  dressing  was  renewed,  and  a 
small  purulent  shred  of  tissue,  which  unfortunately  was  not  examined,  escaped  on 
pressure.  There  was  moderate  and  limited  suppuration  on  the  25th.  On  March 
3d  the  temperature  was  103.3°  Fahr.  Several  deep  incisions  were  made,  which 
gave  exit  to  pus  and  to  a  quantity  of  offensive  gas,  which  was  probably  the  cause 
of  emphysema  which  had  been  observed  in  the  thigh.  On  March  9th,  while  the 
wound  was  being  cleansed,  the  whole  of  the  tibialis  anticus  was  drawn  out :  and 
on  the  10th  the  extensor  of  the  great  toe  and  the  common  extensor  of  the  toes 
were  removed.  These  muscles  were  quite  necrosed,  and  had  a  peculiar  waxy 
colour.  Microscopic  examination  showed,  towards  the  upper  end,  small  quanti- 
ties of  colouring  matter  of  the  blood  and  crystals  of  haematin.  The  subsequent 
progress  of  the  case  was  very  favourable ;  the  patient,  however,  was  obliged  to 
wear  an  apparatus  to  counteract  the  preponderance  of  the  sural  muscles  arising 
from  the  loss  of  the  extensors  of  the  legs.  The  necrosis  was  probably  due  to 
embolism  of  the  artery  supplying  the  parts.  The  pulsation  in  the  dorsal  artery 
of  the  foot  remained  unaffected  throughout. — London  Med.  Record,  June  15, 
1878. 

Effect  of  Posture  on  the  Peripheral  Circulation. 
Mr.  Lister  recently  read  a  paper  on  this  subject  before  the  Pans  Academic 
de  Medecine.    According  to  the  report  in  D  Union  Medicate,  he  stated  that  he 


1878.] 


Surgery. 


575 


had  been  led  to  attend  specially  to  the  subject  when  studying  the  resection  of  the 
wrist  for  caries.  In  order  to  prevent  the  hemorrhage  he  applied  Petit's  tourni- 
quet upon  the  arm,  after  having  raised  the  limb  for  some  minutes.  By  this 
mean?  the  limb  was  rendered  almost  exsanguine.  Later,  in  1873,  it  occurred  to 
him  that  this  result  was  not  the  simple  mechanical  effect  of  gravitation,  but  was 
a  reflex  phenomenon  caused  by  the  emptying  of  the  veins  producing  contraction 
of  the  muscular  fibres  of  the  arteries.  In  surgery  this  method  of  raising  a  limb, 
and  then  applying  at  its  root  a  tourniquet,  has  all  the  advantages  of  the  system 
of  Esmarch  without  its  inconveniences,  such  as  the  danger  of  forcing  septic  matters 
into  the  interstices  of  healthy  tissues.  In  order  to  observe  the  effect  better  Mr. 
Lister  performed  the  following  experiment  on  a  horse.  By  means  of  cords  and 
pulleys  attached  to  the  legs  of  a  horse  he  varied  the  position  of  one  hind  leg,  at 
one  time  elevating  it  while  the  animal  was  on  its  back,  at  another  keeping  the 
leg  horizontal  while  the  horse  was  on  its  side,  and  at  another  allowing  it  to  stand 
upright  with  the  leg  downwards.  The  metacarpal  artery  having  been  exposed, 
it  was  seen  that  when  the  leg  was  raised  the  artery  did  not  pulsate,  and  that  the 
wound,  being  cleared  of  blood,  resembled  one  made  after  death.  By  means  of  a 
gauge  the  diameter  of  the  artery  was  ascertained.  When  the  leg  was  raised  the 
diameter  of  the  vessel  scarcely  exceeded  that  of  the  same  artery  divided  and 
emptied,  while  in  the  horizontal  position,  and  especially  while  the  limb  was  de- 
pendent, the  enlargement  of  the  vessel  was  considerable.  By  calculating  the 
internal  area  from  the  external  diameter,  it  was  estimated  that  on  changing  the 
position  from  an  elevated  to  a  horizontal  position,  the  calibre  of  the  vessel  was 
increased  threefold,  and  that  it  became  increased  sixfold  when  the  limb  hung 
down. 

Mr.  Lister  demonstrated  the  effect  of  his  method  on  the  arm  of  one  of  the 
servants  of  the  Academy,  and  showed  that  if  a  limb  was  raised  and  a  tourniquet 
applied  it  remained  pale  and  bloodless,  even  when  it  was  allowed  to  hang  down, 
and  on  raising  the  limb  again  and  removing  the  pressure,  the  colour  rapidly  re- 
turned to  it,  in  spite  of  its  position,  which  was  the  same  as  that  in  which  it  had 
become  pale  and  exsanguine  before  the  application  of  the  tourniquet.  He  ex- 
plained this  result  by  supposing  that  after  the  tissues  of  a  limb  have  been  deprived 
for  a  certain  time  of  all  circulation,  there  is,  so  to  speak,  a  need  for  the  circula- 
tion, and  that  this  need  acts  as  a  stimulus,  and  determines  a  relaxation  of  the 
arteries  by  acting  on  the  vaso-motor  system  just  as  warmth  does.  This  stimulus 
of  need  of  circulation,  which  causes  the  relaxation  of  the  arteries,  becomes  stronger 
than  the  stimulus  of  relaxation  of  the  veins  excited  by  gravitation,  which  under 
other  circumstances  would  have  caused  their  contraction.  In  consequence,  the 
reaction  is  strong  in  proportion  to  the  duration  of  the  constriction.  Another 
experiment  consisted  in  exciting  the  circulation  by  a  short  run,  then  raising  the 
arm  for  a  few  minutes,  and  then  lowering  it.  The  member  became  reddened 
and  congested  just  as  after  the  application  of  cold.  As  evidence  that  these  phe- 
nomena depend  on  a  reflex  action,  Mr.  Lister  pointed  out  that  if  their  cause 
were  purely  mechanical  and  physical,  the  lower  part  of  the  artery  of  a  raised 
limb  would  have  increased  in  size,  since  it  would  have  been  overfilled ;  but  the 
actual  state  is  the  reverse.  The  femoral  artery  of  the  leg  of  a  calf  was  exposed 
close  to  the  abdomen.  After  the  contraction  caused  by  the  irritation  of  the  ope- 
ration had  ceased,  he  measured  the  external  diameter  of  the  vessel  in  different 
positions  of  the  animal,  and  the  results  accorded  exactly  with  his  previous  con- 
clusions. Finally,  Mr.  Lister  pointed  out  the  application  of  the  theory  to  several 
phenomena,  such  as  the  good  effects  of  the  elevation  of  parts  the  seat  of  inflam- 
mation, and  the  treatment  of  epistaxis  by  elevation  of  the  arm.  Raising  the  arm 
produced,  according  to  him,  a  reflex  contraction  of  the  arteries  of  the  upper  limbs, 


576 


Progress  of  the  Medical  Sciences. 


[Oct. 


and,  consequently,  a  sympathetic  contraction  of  the  facial  arteries,  leading  to  the 

cessation  of  the  hemorrhage. — Lancet,  June  29,  1878. 

Application  of  the  Poro-plastic  Felt  Jacket. 
Mr.  William  Adams,  before  the  Surgical  Section  of  the  British  Medical 
Association  (British  Med.  Journal,  Aug.  24,  1878),  gave  a  practical  demonstra- 
tion of  the  mode  of  applying  the  poro-plastic  felt  jacket  during  suspension  in 
cases  of  spinal  disease  and  spinal  curvature,  in  a  manner  similar  to  that  recom- 
mended by  Dr.  Sayre  in  the  application  of  the  plaster-of- Paris  jacket.  Mr. 
Adams  considered  that  the  American  system  of  treating  spinal  disease  with  angular 
curvature,  as  well  as  some  cases  of  lateral  curvature,  by  suspension,  and  the  appli- 
cation during  suspension  of  a  plaster-of- Paris  jacket,  was  the  greatest  advance 
recently  made  in  the  treatment  of  these  affections.  The  system  of  extension  by 
the  head,  as  well  as  by  the  arms,  is  said  to  have  been  of  ancient  date.  It  was 
certainly  practised  in  London  by  Mr.  Stafford  more  than  thirty  years  ago,  and 
the  apparatus  for  head  extension  is  figured  in  his  work  on  the  spine.  Mr.  Adams 
had  for  more  than  twenty  years  practised  extension  by  the  arms,  using  for  this 
purpose  the  trapeze  bar,  in  cases  of  lateral  curvature,  and  the  effect  of  extension 
in  straightening  the  spinal  curvature  was  well  known.  English  surgeons,  how- 
ever, always  trusted  to  recumbency  and  gymnastics  for  retaining  any  advantage 
gained.  The  originality  of  the  idea  of  retaining  the  advantage  gained  by  sus- 
pension, by  the  application  of  a  plaster-of-Paris  bandage  or  jacket  whilst  the 
body  is  suspended,  is  undoubtedly  of  American  origin,  and  it  is  to  Dr.  Sayre  that 
English  surgeons  are  indebted  for  the  knowledge  of  this  system  of  treatment. 
The  substitution  of  the  material  known  as  poro-plastic  felt,  which  has  been  used 
for  some  years  both  in  America  and  in  England,  for  fracture-splints,  etc.,  for  the 
plaster-of-Paris  bandage  or  jacket,  will,  it  is  hoped,  overcome  many  of  the  objec- 
tions raised  to  the  use  of  the  plaster-of-Paris  jacket.  Experiments  with  the  poro- 
plastic  felt  were  made,  at  the  suggestion  of  Mr.  Adams,  in  the  early  part  of  the 
present  year  by  Mr.  Ernst,  witli  the  assistance  of  the  inventor.  Mr.  Cocking. 
Mr.  Ernst  has  now  brought  the  poro-plastic  felt  jacket  to  a  high  degree  of  per- 
fection, as  shown  by  its  application  to  several  cases  before  the  meeting.  Mr. 
Fisher  has,  at  the  National  Orthopaedic  Hospital,  applied  a  large  number  of  these 
jackets,  and  considers  them  to  be  quite  as  efficient,  and,  in  many  respects,  supe- 
rior to  the  plaster-of-Paris  jacket.  These  poro-plastic  spinal  jackets  canuot  be 
made  out  of  the  sheet  felt,  but  must  be  manufactured  on  wooden  blocks,  and  are 
kept  in  different  sizes.  After  the  proper  measures  have  been  taken,  one  of  the 
jackets  approximating  to  the  required  size  is  softened  in  an  oven,  or  hot-air  cham- 
ber, at  a  temperature  of  180  deg.  This  occupies  from  three  to  five  minutes, 
during  which  time  the  patient  is  being  suspended,  precisely  in  the  same  way  as 
when  Sayre's  plaster-of-Paris  jacket  is  applied,  and  a  tightly-fitting  gauze  vest  is 
drawn  over  the  body.  The  body  is  then  wrapped  round  with  a  sheet  of  cotton- 
wool, which  forms  a  soft  padding,  and  is  useful  as  a  non-conductor  of  heat. 
This  was  suggested  by  Dr.  Yandell,  of  Kentucky.  The  softened  jacket  is  then 
applied,  and  rapidly  moulded  to  the  trunk  whilst  the  patient  is  suspended.  It 
is  then  buckled  in  front,  and  a  broad  bandage  is  firmly  and  rapidly  applied 
round  the  jacket  from  the  top  to  the  bottom  ;  the  patient  still  being  suspended. 
In  two  minutes  from  the  time  of  application,  the  jacket  will  be  found  to  be  cool 
and  firmly  set,  and  the  process  complete.  It  can  be  removed  at  pleasure  for  the 
purposes  of  sleep,  washing,  and  gymnastic  exercises,  so  useful  in  lateral  curva- 
ture. It  can  be  softened  and  reapplied,  as  improvement  in  the  spinal  curvature 
takes  place  ;  and  the  same  jacket  will  last  a  year  or  more. 


1878.] 


Surgery. 


577 


Varicose  Ulcer  and  its  Treatment. 
Mr.  John  Gay,  in  another  of  his  instructive  papers,  explains,  in  the  Lancet, 
June,  1878,  p.  928.  that  the  essential  factors,  in  respect  of  a  varicose  ulcer,  are 
extreme  degeneration  of  the  vein,  and  resultant  incompetency  of  its  valve — 
always  a  barrier- valve,  that  is,  a  valve  that  intercepts  all  regurgitation  of  blood, 
or  any  attempt  to  force  the  finest  injection  from  above,  through  one  such  barrier, 
to  a  segment  below,  which  barrier- valves  are  placed  in  certain  situations  on  the 
venous  circulation  of  the  leg.  One  is  met  with  a  short  distance  below  the  knee- 
joint  ;  a  second  a  short  distance  above  the  ankle-joint ;  a  third  immediately  below 
that  joint.  A  varicose  ulcer  is  always  met  with  in  close  contiguity  to  one  of 
these  barriers,  especially  those  above  and  below  the  ankle-joint,  and  is  closely 
associated  with  incompetency  in  a  saphenous  tributary — not  the  saphena  itself. — 
London  Med.  Record,  Aug.  15,  1878. 

The  Transplantation  of  Tissues. 
A  series  of  systematic  experiments  on  the  transplantation  of  tissues  has  recently 
been  earned  out  by  Dr.  Zahx.  The  first  observations  were  made  on  the  transfer 
of  hyaline  cartilage  from  one  adult  animal  to  another.  The  tissues  into  which 
the  fragments  were  implanted  were  the  subcutaneous  connective  tissue,  the 
anterior  chamber  of  the  eye,  the  submaxillary  glands,  the  kidneys,  the  testicles, 
and  the  bloodvessels.  These  attempts  yielded,  however,  negative  results  ;  the 
cells  of  the  tissue  perished,  the  intercellular  tissue  persisted,  but  the  fragment 
became  encapsuled  by  connective  tissue.  The  experiments  were  much  more 
successful  when  the  fragment  was  taken  from  foetal  cartilage,  which  showed  a 
remarkable  capability  of  developing  in  another  organism,  even  in  that  of  an  adult 
animal.  If  some  cartilage  were  rubbed  up  with  amniotic  fluid,  the  smallest  quan- 
tity of  the  mixture  produced,  in  about  six  weeks,  nodules  of  cartilage  the  size  of 
a  lentil  seed.  On  injecting  this  mixture  into  the  jugular  vein,  numerous  growths 
of  cartilage  were  subsequently  found  in  the  lungs.  The  capacity  of  foetal  cartilage 
to  develop  is  so  great  that  these  results  were  obtained,  not  only  with  animals  of 
the  same  species,  but  even  with  those  of  different  species.  For  instance,  carti- 
lage from  the  foetus  of  the  cat  gave  rise  to  nodules  in  rabbits.  Experiments  were 
also  made  with  the  cartilage  from  an  enchondroma,  with  less  uniform  success 
than  with  foetal  cartilage,  but  with  much  more  success  than  with  ordinary  adult 
cartilage.  In  several  instances  the  attempts  to  transplant  it  were  successful. 
This  is,  it  is  hardly  necessary  to  point  out,  a  result  of  much  interest  in  connection 
with  the  diffusion  of  enchondromatous  growths.  "With  other  foetal  tissues  Zahn 
was  also  successful.  A  piece  of  growing  bone,  for  instance,  became  connected 
with  the  bloodvessels  of  the  tissue  into  which  it  was  placed  and  became  nourished. 
Eutire  bones  were  even  thus  implanted,  and,  although  they  did  not  grow  as  a 
whole,  they  preserved  their  form,  and  outgrowths  occurred — exostoses  and  en- 
chondromata — at  both  the  epiphyses  and  diaphyses.  From  these  experiments, 
and  those  of  previous  investigators,  Zahn  concludes  that  only  foetal  tissues,  and 
such  adult  tissues  as  preserve  their  foetal  peculiarities,  can  develop  in  another 
animal,  or  in  another  part  of  the  same  animal.  Only,  for  instance,  the  red 
marrow  will  do  so,  and  the  periosteum  of  young  individuals.  Such  tissues  alone 
possess  the  capability  of  persisting  until  they  have  come  into  relation  with  the 
new  organism. — Lancet,  August  24,  1878. 


No.  CLII  Oct.  1878.  37 


578 


Progress  of  the  Medical  Sciences. 


[Oct. 


OPHTHALMOLOGY  AND  OTOLOGY. 

Iodoform  in  Eye-Disease. 

Mr.  Patrick  J.  Hayes,  of  Dublin,  calls  attention  {Med.  Times  and  Gaz., 
Aug.  17,  1878)  to  the  value  of  iodoform  as  a  therapeutic  agent  in  the  treatment 
of  certain  subacute  and  chronic  diseases  affecting  the  eyes  and  eyelids. 

Many  practitioners  are  of  course  aware  that  for  a  considerable  time  iodoform 
has  been  used  as  an  application  in  cases  of  trachoma  or  granular  lids,  and  reports 
have  been  published,  in  America  and  elsewhere,  illustrative  of  the  good  results 
which  frequently  ensue  upon  its  employment.  Mr.  Hayes  has  not,  however, 
seen  any  recommendation  of  it  for  such  cases  as  phlyctenular  and  pustular  oph- 
thalmia, corneal  ulceration,  obstinate  keratitis,  ciliary  blepharitis,  etc.;  hence, 
as  he  has  found  it  to  benefit  several  patients  so  affected,  he  ventures  to  invite  for 
it  a  trial  at  the  hands  of  his  confreres.  With  respect  to  the  method  of  applica- 
tion, it  is  his  custom  to  crush  the  crystals  until  they  become  reduced  to  a  very  fine 
powder,  and  then,  with  a  delicate  camel' s-hair  pencil,  the  powder  is  freely 
dusted  over  the  affected  surface.  For  use  upon  the  eyelids  such  an  ointment  as 
the  following  will  be  found  convenient:  Iodoform,  1  part;  vaseline,  4  parts — mix. 

Iodoform,  when  brought  into  contact  with  the  eye,  does  not  give  rise  to  pain, 
and  children  who  have  once  experienced  its  effect  will  readily  tolerate  subsequent 
applications. 

Mr.  Hayes  adds  that  it  is  not  suitable  for,  and  ought  not  to  be  used  during,  the 
early  or  acute  stage  of  conjunctivitis. 

Case  of  Gummy  Tumour  of  the  Conjunctiva. 

Dr.  Albrecht  Berger  relates  this  case  in  the  Aerztliches  Intelligenz-blatt, 
April  23,  1878.  On  November  8,  1877,  a  young  married  woman,  aged  30, 
applied  to  Dr.  Berger  at  Munich  on  account  of  a  sudden  dilatation  of  the  pupil 
of  her  left  eye.  The  eye  was  free  from  pain,  and  presented  nothing  abnormal 
on  ophthalmoscopic  examination,  but  the  pupil  was  widely  dilated  and  fixed. 
There  was  a  faint  copper-tinted  eruption  on  the  forehead  ;  and,  although  no  his- 
tory of  syphilis  could  be  obtained,  the  case  was  considered  to  be  one  of  that 
nature.  Under  treatment  with  iodide  of  potassium,  the  constant  current,  and  the 
instillation  of  eserine,  the  pupil  resumed  its  normal  appearance  and  functions  in 
about  three  weeks. 

In  January,  1878,  the  patient  presented  herself  again  in  the  following  condi- 
tion. She  looked  cachectic  and  extremely  ill ;  there  was  a  well-marked  syphilitic 
eruption  on  the  forehead  and  face,  and  some  swelling  of  the  cervical  glands ;  the 
skin  of  the  upper  lid  of  the  right  eye  was  red  and  thickened,  and  covered  with  a 
scaly  eruption ;  the  iris  of  this  eye  was  discoloured  and  indistinct,  and  the  pupil 
contracted  and  fixed.  At  the  inner  margin  of  the  cornea,  beneath  the  conjunc- 
tiva, was  a  small  round  nodule  of  a  yellowish-pink  colour,  around  which  was  a 
zone  of  extremely  congested  vessels  ;  the  cornea  itself  was  hazy  at  this  spot.  On 
the  left  side,  the  eyelids  were  covered  with  a  similar  scaly  eruption,  but  the  pupil 
acted  properly,  and  the  eye  appeared  in  every  respect  normal. 

The  patient  was  put  under  the  influence  of  mercury,  but  the  inflammatory  pro- 
cess rapidly  increased  and  the  nodule  became  much  enlarged  ;  at  the  same  time  a 
brown-red  mass  of  lymph  made  its  appearance  upon  the  anterior  surface  of  the 
iris  ;  this  rapidly  occupied  the  inner  quadrant  of  the  anterior  chamber,  and  came 
in  contact  with  the  back  of  the  cornea.  Having  reached  this  point  it  as  rapidly 
receded  and  diminished  in  size,  and  about  eight  days  afterwards  the  pupil  became 


1878.] 


Midwifery  and  Gynaecology. 


579 


dilated  under  the  use  of  atropine,  and  a  reddish-yellow  stain  was  all  that  remained 
upon  the  iris ;  at  the  same  time,  the  conjunctival  swelling  gradually  diminished. 

In  this  instance,  the  gummy  swelling  was  associated  with  a  dilated  pupil  with- 
out any  impairment  of  the  accommodation,  and  with  no  implication  of  any  of  the 
muscles,  although  the  coexistence  of  a  specific  eruption  pointed  to  the  origin  of 
the  affection  as'  being  syphilitic.  Soelberg  Wells  has  described  a  form  of  my- 
driasis as  the  result  of  syphilis  ;  and  De  Meric  (British  Medical  Journal,  1869) 
has  put  upon  record  four  cases  in  which  mydriasis  with  ptosis  was  observed,  and 
two  others  in  which  mydriasis  occurred  alone;  and  Wecker  (Maladies  des  Yeux), 
as  also  Erlander  (Klin.  Mo  n  at  sb  I  titter,  1870),  has  described  cases  which  bear  a 
close  resemblance  to  the  case  above  recorded. — London  Med.  Record,  June  15, 
1878. 

Daltonism  :  Sanitary  Precautions  and  Preventive  Measures. 

M.  A.  Fabrk  communicated  to  the  Academie  des  Sciences  (Gaz.  Hebdoma- 
daire,  June  14,  1878)  a  note  which  is  summarized  in  the  following  conclusions  : — 

1.  Daltonism  consists  in  ignorance  or  confusion  of  colours.  2.  There  are  in 
France  more  than  3,000,000  persons  affected  with  Daltonism.  3.  The  number  of 
females  attacked,  as  compared  with  men,  is  about  one  to  ten.  4.  In  nine  out  of 
ten  cases  it  may  be  easily  cured  in  young  subjects.  5.  The  best  means  of  treat- 
ment consists  in  methodical  exercise  of  the  eyes  on  coloured  objects.  6.  The 
women  of  a  family  ought  to  undertake  the  development  of  the  chromatic  sense  in 
children,  and  especially  those  who  may  commit  errors  in  the  denomination  of 
colours.  They  should  be  careful  not  to  ridicule  these  "  Daltonians."  7.  In 
future  no  one  ought  to  be  admitted  into  the  service  of  the  railways,  the  marine, 
or  schools  of  painting  without  an  examination  as  to  colours.  8.  Ignorance  of 
colours  should  not  exempt  from  service  in  armies  by  land  or  sea,  but  the  "Dalto- 
nians" should  never  be  intrusted  with  any  service  connected  with  coloured  sig- 
nals. Regular  exercises  in  colours  should  be  instituted  both  in  the  marine  and  the 
army.  9.  Examinations  and  exercises  in  colours  should  be  established  in  all 
schools. — Med.  Times  and  Gaz.,  June  22,  1878. 


MIDWIFERY  AND  GYNECOLOGY. 

Induction  of  Premature  Labour. 
Dr.  Schauta,  assistant  of  Dr.  Spath,  in  the  Vienna  Midwifery  Clinic,  in  an 
article  in  the  Wiener  Med.  Woch.,  May  11,  observes  that  some  time  since  he 
perused  an  account  of  two  dropsical  women  in  whom  Dr.  Massmann,  of  St. 
Petersburg,  had  employed  a  hypodermic  injection  of  pilocarpin  for  the  purpose 
of  inducing  sweating.  It  happened  that  both  these  women  were  pregnant,  and 
in  both  premature  labour  occurred  a  few  hours  after  the  pilocarpin  was  adminis- 
tered. These  cases  did  not  prove  much,  as  they  were  not  very  exactly  observed 
as  regards  the  period  of  pregnancy,  while  premature  labour  is  not  an  uncommon 
occurrence  in  dropsical  pregnant  women  having  Bright' s  disease.  Still,  he  re- 
solved on  the  first  occasion  that  presented  itself  to  test  the  power  of  pilocarpin  as 
an  abortive  agent.  On  May  1st  a  primipara  aged  twenty-two  was  admitted,  and 
a  minute  account  of  her  condition  and  of  the  measurements  of  the  pelvis  is  fur- 
nished. It  will  suffice  to  say  that  she  was  robust  and  in  good  health,  with  no 
signs  of  rickets  presenting  themselves,  her  last  menstruation  being  supposed  to 


580 


Progress  of  the  Medical  Sciences. 


[Oct. 


have  occurred  on  August  2  to  6,  187  7.  However,  the  pelvis  having  been  found 
so  contracted  that  the  passage  of  a  child  at  the  normal  end  of  pregnancy  would 
be  exceedingly  doubtful,  Prof.  Spilth  consented  to  an  attempt  at  induction  of 
labour  by  means  of  pilocarpin.  On  May  3d,  at  3.23  P.  M.,  the  contents  of  a 
Pravaz  syringe  full  of  a  2  per  cent,  solution  of  the  muriate  of  pilocarpin  were 
hypodermically  injected  in  the  left  thigh.  The  first  results  observed  at  the  end 
of  4  minutes  were  dilatation  of  the  pupils  (which  had  been  contracted),  disposi- 
tion to  vomit,  sweating  of  the  face,  and  a  flow  of  saliva,  which  were  soon  followed 
by  a  sweetish  taste  in  the  mouth  and  trembling  of  the  lower  extremities.  The 
secretion  of  sweat  then  rapidly  appeared  over  the  whole  body,  increasing  at  the 
same  time  on  the  face.  At  the  end  of  a  quarter  of  an  hour  the  sweating  had 
reached  its  maximum,  and  then  became  quickly  arrested,  chilliness  as  if  from 
evaporation  replacing  also  the  former  sense  of  heat.  The  salivation,  which  had 
kept  pace  with  the  sweating  in  intensity,  also  ceased  almost  suddenly,  although  a 
relapse  lasting  for  2  minutes  occurred  26  minutes  after  the  injection  had  been 
effected.  During  the  whole  time  the  thermometer  in  the  axilla  remained  un- 
changed (36.8°  Celsius),  the  pulse  rising  from -68  to  between  92  and  100,  and  the 
respirations  increasing  from  24  to  40.  All  these  phenomena  then  abated,  so  that 
by  5  o'clock  the  patient's  state  had  become  quite  normal,  or,  as  she  expressed  it, 
she  felt  just  as  she  did  in  the  morning.  When  seen  at  6.15  she  stated  that  she 
had  since  felt  painful  contractions  in  the  abdomen.  Her  temperature  was  the 
same,  the  pulse  being  72,  and  the  respirations  32.  An  examination  was  made, 
and  the  cervix,  which  had  been  firmly  closed,  was  found  to  be  looser,  its  canal 
admitting  the  finger  to  the  extent  of  3  centimetres  ;  and  t  he  head  was  plainly  felt 
through  the  membranes.  She  had  some  hours'  interrupted  sleep,  but  perceived 
no  pains.  Examined  again  at  10  o'clock  :  the  canal  of  the  cervix  was  found  more 
dilated  and  only  2  centimetres  in  length,  the  membranes  being  distended.  Be- 
sides the  mucus  on  the  finger,  some  blood  was  observed.  At  10.7  another 
injection  of  pilocarpin  was  made  on  the  left  forearm,  and  in  two  minutes  after- 
wards sweating  of  the  face  appeared ;  and  the  phenomena  succeeded  each  other 
exactly  as  they  did  after  the  first  injection,  even  to  the  occurrence  of  the  relapse 
of  the  salivation  at  the  end  of  25  minutes.  Shortly  after  11  o'clock  the  patient 
fell  .asleep,  and  awoke  at  5  in  the  morning,  complaining  of  pains  in  the  abdomen 
and  a  sense  of  pressure  downwards.  By  5.45  the  pains  had  set  in  regularly,  and 
(without  going  further  into  details)  the  labour  was  terminated  at  8.25  by  the 
birth  of  a  living  female  infant.  The  placenta  was  discharged  spontaneously  at 
the  end  of  20  minutes,  and  the  uterus  contracted  well.  At  the  date  of  the  report 
(May  9th)  both  mother  and  child  were  doing  well. 

The  child  weighed  2275  grammes  and  measured  47  centimetres.  That  its 
birth  exhibited  the  power  of  the  pilocarpin  is  shown  by  the  fact  that  the  mother 
during  several  days  she  had  been  under  observation  had  not  felt  the  slightest 
pain,  the  cervix  also  remaining  prior  to  the  injection  completely  closed ;  while 
after  the  administration  of  this  the  action  became  rapid  and  energetic.  Dr. 
Schauta  believes  that  this  case  and  those  reported  by  Dr.  Massmann  at  all  events 
show  decidedly  the  desirableness  of  additional  trials  of  pilocarpin  being  made 
with  respect  to  feeble  pains,  abortion,  etc. — Med.  limes  and  Gaz.,  July  13,  1878. 

The  Revolutions  of  the  Foetal  Head  in  Passing  through  a  Brim  contracted  only 
in  the  Conjugate  Diameter. 
A  laboratory  note  on  this  subject  was,  at  a  recent  meeting  of  the  Obstetrical 
Society  of  London  (Med.  Times  and  Gaz.,  June  22,  1878),  contributed  by  Dr. 
Matthews  Duncan.  The  only  point  considered  in  the  note  was  movements 
of  the  foetal  skull  in  a  coronal  plane — that  is,  revolutions  around  the  pubic  part 


1878.] 


Midwifery  and  Gynaecology. 


581 


of  the  pelvic  brim  and  around  the  promontory  of  the  sacrum — movements  re- 
sembling right  and  left  lateral  flexion,  or  like  revolution  in  an  internal  or  occipito- 
frontal axis.  From  this  last  kind  of  movements  the  revolutionary  movements 
were  distinct,  because  the  revolutionary  movement  on  an  external  axis  implied 
progress  of  the  head  as  a  whole,  and  not  mere  movement  in  itself.  Dr.  Duncan's 
conclusions  were  based  chiefly  on  experiments  with  fresh  mature  foetuses  and 
modern  pelvic  brims,  and  tallied  remarkably  with  the  results  of  clinical  observa- 
tion of  the  progress  of  the  head  in  head-last  and  in  head-first  cases  in  simple  narrow 
pelves.  Recent  inquiries  into  this  subject  had  increased  our  practical  usefulness 
distinctly,  and  further  elucidation  of  it  was  desirable.  The  experiments  were 
made  in  imitation  of  footling  cases,  and  the  first  result  of  traction  through  the 
spine  was  a  revolution  around  the  pubic  part  of  the  brim,  the  sagittal  suture  ap- 
proximating to  the  pubes.  The  side  of  the  base  of  the  skull  placed  posteriorly 
passed  first  through  the  contraction  and  during  the  first  revolution.  The  side  of 
the  vault  of  the  skull  placed  anteriorly  passed  first,  and  during  the  second  or 
greater  revolution.  Litzmann,  Kleinwechter,  and  Spiegelberg  described  only 
the  first  revolution,  or  rather  its  analogue  in  head-first  cases.  Burner  described 
only  the  second  or  greater  revolution.  Goodell,  in  singular  accordance  with  the 
conclusions  of  this  note,  described  two  movements,  but  not  as  revolutions ;  and 
he  made  this  accurate  description  of  both  head-first  and  head-last  cases.  The 
movement  of  the  sagittal  suture  towards  the  sacrum  (and  the  base  of  the  foetal 
skull  in  nearly  an  opposite  direction),  in  the  first  part  of  the  passage  in  head-last 
cases,  was  analogous  to  the  movement  of  the  sagittal  suture  forwards  at  the  same 
stage  of  a  head-first  case.  In  both  the  head  was  revolving  to  a  slight  degree  on 
the  pubic  part  of  the  brim  of  the  pelvis.  The  movement  of  the  sagittal  suture 
towards  the  symphysis  (and  the  base  of  the  foetal  skull  in  nearly  an  opposite 
direction),  in  the  second  and  greater  part  of  the  passage  in  head-last  cases,  was 
analogous  to  the  movement  of  the  sagittal  suture  backwards  or  towards  the  hollow 
of  the  sacrum  at  the  same  stage  of  a  head-first  case.  In  both  the  head  was 
making  its  greater  revolution  on  the  promontory  of  the  sacrum. 

The  Etiology  of  Face  Presentations. 
In  a  paper  published  in  the  Archiv  fur  Gynakologie,  B.  xii.  H.  2,  Dr.  Mayr 
maintains  a  view  similar  to  that  of  Hecker  on  the  influence  of  the  primary  shape 
of  the  skull  in  the  production  of  face  presentations,  and  supports  it  by  statistics 
derived  from  the  Lying-in  Hospital  at  Munich.  In  14,519  deliveries  there  were 
107  face  presentations,  or  0.73  per  cent.,  and  15  brow  presentations,  or  0.103  per 
cent.  The  number  of  first  positions  of  the  face  to  second  positions  was  in  the 
ratio  1.4  to  1.  Hecker' s  statistics  give  a  ratio  of  1.3  to  1,  and  therefore  taking 
the  normal  ratio  of  first  to  second  positions  of  the  vertex  as  being  2.3  to  1,  it  is 
proved  that  a  face  presentation  arises  more  easily  when  the  back  of  the  child  lies 
to  the  right.  The  mean  direction  of  the  first  stage  of  labour  in  38  primiparae  was 
23.6  hours;  that  in  69  multipara?,  14.5  hours.  The  mean  duration  in  the  second 
stage  in  the  38 -primiparae  was  12^-  hours;  in  the  69  multipara?,  1.26  hours.  The 
general  duration  of  labour  was  therefore  considerably  greater  than  in  vertex  pre- 
sentations, although  it  was  accelerated  artificially  in  a  greater  proportion  of  cases. 
Version  was  not  employed  'in  any  of  the  107  cases,  but  forceps  were  used  seven 
times,  or  in  6.5  per  cent,  of  the  cases,  the  general  forceps  ratio  being  only  2.5 
per  cent.  Rupture  of  the  perineum  occurred  in  seven  cases,  but  in  none  of  those 
in  which  forceps  were  employed.  This  gives  a  proportion  of  6.5  per  cent,  of 
ruptured  perineum,  while  that  in  vertex  presentations  was  4.6  per  cent.  Of  the 
107  mothers,  11  suffered  from  puerperal  maladies.    Four  patients  delivered  by 


582 


Progress  of  the  Medical  Sciences. 


[Oct. 


forceps  suffered  from  puerperal  peritonitis.  Three  of  these  died  ;  the  fourth  was 
removed  while  seriously  ill,  and  the  issue  was  not  ascertained.  Another  case  of 
severe  puerperal  disease  was  also  removed,  and  the  result  remained  unknown. 
Thus  cases  of  face  presentation  gave  a  mortality  of  2.8  per  cent,  or  more,  and  a 
morbility  of  10.3  per  cent.,  as  against  a  general  mortality  of  1.7  per  cent.,  and  a 
general  morbility  of  4.7  per  cent.  As  to  the  children,  52  were  male,  55  female; 
2.8  percent,  were  dead  before  labour  commenced,  as  against  a  general  percent- 
age of  2.19;  6.54  per  cent,  died  during  labour  or  shortly  after  delivery,  as 
against  a  general  percentage  of  3.1.  Face  presentation  is  therefore  shown  to 
involve  a  considerable  increase  of  danger  both  to  mother  and  child. 

With  regard  to  the  causes  which  promote  face  presentations,  the  author  found 
that  in  63  cases  the  proportion  of  the  weight  of  the  child  to  its  length  was  above 
the  normal  mean  ratio,  and  in  4  7  cases  was  below  it.  The  mean  in  face  presen- 
tations was  .6699  grm.  in  weight  per  100  em.  of  length  ;  the  normal  mean,  as 
derived  from  the  statistics  of  various  authors,  being  .6484  grm.  per  100  cm.  in 
length.  There  is,  therefore,  some  confirmation  for  the  inference  arrived  at  by 
Ahlfeld  on  the  ground  of  theoretical  mechanics,  that  the  greater  the  weight  of  a 
child  in  proportion  to  its  length,  the  more  readily  is  a  face  presentation  produced. 
The  heads  were  measured  after  delivery  as  to  their  circumference,  antero-posterior 
diameter,  diagonal  (or  maximum)  diameter,  and  greatest  transverse  diameter, 
and  many  of  them  were  also  measured  after  the  lapse  of  a  week.  The  mean 
circumference  was  found  to  be  0.93  cm.  above  normal;  mean  diagonal  diameter, 
0.26  cm.  below  normal ;  mean  antero-posterior  diameter,  0.59  cm.  above  normal ; 
mean  transverse  diameter,  0.11  cm.  above  normal.  These  results  coincide  with 
those  of  Hecker  in  showing,  in  cases  of  face  presentation,  an  excessive  prolonga- 
tion of  the  occiput,  and  an  excessive  maximum  transverse  diameter.  The  author 
thinks  that  the  former  is  due  in  part  to  the  mechanism  of  delivery,  but  that  this 
is  not  sufficient  to  account  for  the  whole. 

In  normal  skulls  the  antero-posterior  diameter  is  1.72  cm.  less  than  the  diago- 
nal (or  maximum)  diameter ;  in  the  cases  of  face  presentation  the  mean  differ- 
ence was  only  0.87  cm.  In  46  of  these,  measured  again  after  the  interval  of  a 
week,  the  mean  difference  was  1.11  cm.  The  author  has  no  corresponding 
figures  for  skulls  delivered  by  the  vertex,  and  measured  at  the  end  of  a  week. 
Budin,  however,  from  heads  measured  forty-eight  hours  after  birth,  at  which 
time  he  considers  them  to  have  recovered  their  normal  shape,  gives  a  difference 
between  the  diagonal  and  antero-posterior  diameters  of  1.75  cm.,  somewhat 
greater  than  that  immediately  after  delivery.  The  author  therefore  concludes 
that  this  unusual  length  of  the  antero-posterior,  compared  with  the  maximum 
diagonal  diameter,  by  which  is  implied  an  excessive  projection  of  the  occiput, 
was  a  primary  quality  of  the  heads  delivered  by  face  presentation,  and  not 
merely  the  result  of  the  mechanism  of  labour.  This  confirms  the  view  of  Hecker, 
and  is  in  opposition  to  the  results  of  Budin,  who  found  that  heads  delivered  by 
face  presentation  returned  after  a  time  completely  to  the  normal  outline. 

Besides  the  effect  of  excessive  projection  of  the  occiput,  by  which  the  leverage 
of  resistance  or  friction  applied  to  the  occiput  is  increased,  the  author  thinks  that 
light  is  also  thrown  upon  the  mechanism  of  face  presentations  by  the  fact  that 
heads  so  delivered  have  an  excessive  maximum  transverse  or  biparietal  diameter. 
For  if  this  be  the  case,  tne  head  will  be  most  tightly  gripped  by  the  brim  in  the 
biparietal  diameter,  its  axis  of  motion  relatively  to  the  pelvis  will  be  at  this  point, 
or  further  back  than  usual,  and  the  effect  of  the  expulsive  force  will  then  be  to 
cause  extension  of  the  head. — Obstetrical  Journal  of  Great  Britain.  Sept.  1878. 


1878.]  Midwifery  and  Gynaecology.  583 

The  Treatment  of  Sore  Nipples. 
Dr.  Haussmann's  plan  of  treating  sore  nipples  by  the  application  of  solutions 
of  carbolic  acid  (see  Monthly  Abstract  for  September,  1878,  p.  425)  has  re- 
cently been  tested  in  the  lying-in  wards  of  the  Berlin  Charite  Hospital.  Instead, 
however,  of  applying  strips  of  lint  saturated  with  the  solution,  Dr.  Steiner  di- 
rected that  the  acid  should  be  brought  into  contact  with  the  sores  by  means  of  a 
camel-hair  brush.  Forty  cases  have  been  thus  treated,  and  with  very  satisfactory 
results.  A  five  per  cent,  solution  seemed  to  be  the  most  efficacious;  its  applica- 
tion may  be  said  to  be  painless,  it  causes  only  a  very  slight  burning.  By  means 
of  the  brush,  the  acid  can  be  applied  to  the  smallest  cracks,  and  two  or  three 
such  daily  applications  are  usually  sufficient.  A  shield,  of  course,  must  be  used 
when  the  child  is  put  to  the  breast.  Dr.  Steiner  has  also  tried  solutions  of  thymol 
(1  to  1000)  for  a  similar  purpose,  but  they  were  found  to  be  far  less  efficacious 
than  the  carbolic  acid. — Med.  Examiner,  Aug.  8,  1878. 

Anatomical  Researches  on  the  Causes  of  Sterility. 
F.  Winckel  has  investigated  the  generative  organs  of  150  sterile  women 
dying  at  a  sexually  mature  age,  and  finds  that,  apart  from  such  causes  as  vaginis- 
mus, which  could  only  be  ascertained  during  life,  the  causes  of  sterility  might  be 
classified  as  follows  :  1.  Mechanical  obstructions.  2.  Chemically  destructive  in- 
fluences. 3.  Disturbances  in  the  nutrition  of  the  ovaries.  In  almost  all  instances 
two  or  all  of  these  conditions  were  present  together  ;  as  in  atresia  of  the  Fallopian 
tubes,  there  were  firm  adhesions  of  the  ovaries  ;  in  myomata  there  was  abnormal 
position,  or  disease  of  the  mucous  membrane,  ovarian  tumours,  etc.  He  only 
admits  stenosis  of  the  os  uteri  to  be  a  cause  of  sterility  when  follicular  catarrh  is 
present  with  accumulation  of  mucus  in  the  cervix.  It  is  only  in  these  cases  that 
Winckel  forces  a  j^assage  and  applies  a  caustic  to  the  membrane. — Lancet,  Aug. 
3,  1878. 

Mr.  Spencer  Wells  on  Ovariotomy. 

Mr.  Spencer  Wells  has  just  completed  a  series  of  six  lectures  on  ovariotomy 
at  the  Royal  College  of  Surgeons.  He  began  by  carefully  defining  his  task. 
' 4  All  that  I  can  do,"  he  says,  "is  to  bring  before  you,  in  the  plainest  manner, 
the  results  of  twenty  years'  exceptionally  large  observation  and  practice  .  .  . 
and  ...  to  tell  what  I  have  learned  about  the  diagnosis  and  surgical  treat- 
ment  of  abdominal  tumours  ;  how  I  have  learned  it ;  the  lessons  I  have  been 
taught  by  mistakes  and  failures  ;  the  satisfaction  which  has  attended  increasing 
success."  These  sentences  accurately  describe  the  scope  of  the  lectures;  beyond 
the  programme  thus  sketched  out  they  do  not  go. 

The  first  lecture  contains  an  account  of  the  mode  of  examining  patients  with 
abdominal  tumours,  and  recording  their  cases.  This  part  is  interesting,  and  fertile 
in  useful  hints ;  but  we  fancy  that  every  surgeon  of  large  experience  soon  falls 
into  a  method  of  note-taking  suited  to  his  own  purpose,  and  is  not  likely  to  bind 
himself  down  to  the  system  of  any  one  else,  however  eminent.  Mr.  Wells  then 
runs  over  the  different  kinds  of  abdominal  tumours  which  have  been,  and,  there- 
fore, may  be,  mistaken  for  ovarian  growths,  noting  the  chief  diagnostic  marks  of 
each.  The  brevity  doubtless  imposed  upon  him  by  his  limited  time  makes  this 
section,  also,  suggestive  rather  than  exhaustive.  We  find  some  remarks,  not  so 
clear  as  we  could  wish,  upon  the  chemical  and  microscopical  characters  of  the 
liquids  drawn  from  ovarian  cysts.  "  A  chemical  and  microscopical  examination 
of  the  fluid  that  is  removed, ' '  says  the  lecturer,  ' '  will  settle  any  doubt  as  to 


584 


Progress  of  the  Medical  Sciences. 


[Oct. 


whether  it  is  free  peritoneal  or  ovarian  fluid,  or  fluid  of  some  other  cvst."  Sub- 
sequently, however,  he  mentions  observations  whieh  appear  to  prove  that  to  diag- 
nostic rules  based  on  this  mode  of  investigation  there  are  exceptions.  We  should 
have  been  glad  of  some  more  definite  statement  of  the  amount  of  weight  to  be 
attached  to  these  facts.  Do,  or  do  not,  the  chemical  and  microscopical  characters 
of  the  fluids  in  question  with  certainty  reveal  their  origin  ?  To  this  question  we 
should  like  to  have  heard  the  answer  of  Mr.  Wells. 

In  the  third  lecture,  we  enter  upon  the  lecturer's  own  special  province.  He 
first  describes  tapping:  its  history,  methods,  and  the  limits  of  its  utility.  Here 
he  expresses  a  decided  opinion,  and  his  dictum  ought  to  be,  and  no  doubt  will  be, 
recognized  as  an  authoritative  rule.  "I  think,"  he  says,  "I  have  seen  quite 
enough  now  to  warrant  me  to  endeavour  to  impress  upon  surgeons  that,  if  the 
cyst  be  a  single  cyst,  before  they  do  anything  else,  they  should  see  what  can  be 
gained  by  one  tapping."  Then  he  comes  to  ovariotomy.  The  rules  which  he 
lays  down  as  to  the  circumstances  under  which  the  operation  should  be  performed1 
are  eminently  judicious.  So  long  as  no  great  inconvenience  is  caused  by  the 
tumour,  the  surgeon  should  hold  his  hand  ;  but  he  should  not  delay  operation  till 
the  patient's  health  is  so  undermined  as  to  compromise  success.  The  mere  size 
of  the  tumour,  and  the  difficulties  met  with  in  the  operation,  do  not  so  much  affect 
the  result  as  the  patient's  constitutional  condition.  The  operation  should  not  be 
associated  with  a  sudden  change,  from  activity  and  excitement  to  the  monotony 
and  restraint  of  the  sick-room.  Almost  the  only  positive  contra-indication  to  an 
operation  is  the  fact  that  the  patient  has  some  other  certainly  fatal  disease.  Even 
the  probability  that  a  tumour  is  cancerous  does  not  absolutely  forbid  its  removal. 

As  to  the  details  of  the  operation,  comment  is  not  needed.  Mr.  "Wells's  success 
is  the  proof  of  the  correctness  of  his  method.  We  may  note,  however,  that  as 
an  anaesthetic  he  prefers  the  bichloride  of  methylene,  which  he  thinks  safer  than 
chloroform.  In  the  management  of  the  pedicle  his  experience  is  greatly  in  favour 
of  the  clamp.  The  result  to  the  patient  is,  he  rightly  says,  the  great  thing  to  be 
considered,  the  thing  with  which  nothing  else  can  be  compared  in  importance  ; 
and  tried  by  this  test,  the  clamp  comes  out  best.  The  justification  of  the  ligature 
is,  that  the  use  of  the  clamp  is  not  practicable  in  every  case.  The  cautery  treat- 
ment Mr.  Wells  has  found  troublesome  and  uncertain.  The  necessity  for  carefully 
counting  forceps,  sponges,  etc.,  was  impressed  upon  the  listeners  by  anecdotes 
narrated  at  length  in  a  dramatic  form. 

In  the  part  of  his  lectures  which  deals  with  the  treatment  of  the  abdominal 
wound,  Mr.  -Wells  refers  to  a  few  valuable  experiments  which  he  has  made  upon 
living  animals.  We  must  say  we  remark  with  much  regret  the  apologetic  tone  in 
which  he  thinks  it  necessary  to  refer  to  them.  He  speaks  of  his  having  been  ac- 
cused of  cruelty,  and  protests  that  the  number  of  experiments  he  has  made  is  but 
small.  But  we  think  that  a  man  in  his  position  should  guide  public  opinion,  and 
not  bend  to  it.  If  he  do  allow  himself  to  be  influenced  by  the  prejudices  of  others, 
it  should  be  by  the  opinion  of  the  educated  public,  the  leaders  of  the  scientific 
world,  and  not  by  the  excited  feelings  of  amiable,  well-meaning,  but  misinformed 
persons.  Those  who,  like  Mr.  Wells,  are  in  the  proud  position  of  not  only  under- 
standing what  science  is,  and  how  scientific  problems  are  to  be  worked  out,  but  of 
possessing  the  confidence  of  the  public,  should  use  their  opportunities  to  lead 
people  to  appreciate  science,  and  should  help  them  to  discriminate  between  those 
whose  knowledge  and  work  make  them  worthy  of  being  heard,  and  those  obscure 
seekers  after  notoriety  whose  only  hope  of  getting  it  lies  in  appealing  to  the  feel- 
ings of  persons  unaccustomed  to  think.  Comparing  this  passage  with  one  in  the 
sixth  lecture,  in  which  Mr.  Wells  implies  that  his  adoption  of  the  antiseptic 
method  was  retarded  by  the  want  of  some  experiments  on  animals  which  he  would 


1878.] 


Midwifery  and  Gynaecology. 


585 


have  liked  to  make,  we  think,  if  lie  apologizes  for  anything,  that  it  should  be  for 
having  so  little  availed  himself  of  this  means  of  interrogating  nature. 

A  topic  upon  which  the  lecturer's  remarks  are  very  interesting,  is  that  of  the 
antiseptic  system.  Hearing  and  seeing  the  great  results  which  had  attended  this 
method,  Mr.  Wells  thought  it  his  duty  to  try  it ;  but  accidental  circumstances 
prevented  his  doing  so  at  the  time  that  he  had  intended,  and,  going  on  in  his  old 
war,  his  results  became  even  more  brilliant  than  had  attended  the  antiseptic 
system  elsewhere,  and  were  not  subsequently  outdone  by  the  new  system  in  Mr. 
Wells's  own  hands.  This  forms  an  instructive  commentary  upon  the  doctrine  of 
contagium  vivum,  as  expounded  by  Dr.  Roberts,  at  Manchester.  To  generate 
disease,  there  are  not  only  needed  morbific  germs,  but  a  soil  in  which  those  germs 
may  live  and  propagate.  Listerism  (as  it  is  called  abroad)  aims  at,  and  succeeds 
in,  destroying  the  germs.  But  if,  by  scrupulous  cleanliness,  these  germs  can  be 
deprived  of  any  soil  in  which  they  can  thrive,  Listerism  is  superfluous.  This 
view  is  borne  out,  not  only  by  Mr.  Wells's  experience,  but  by  Mr.  Calender's 
statistics  of  amputations.  Those  hospitals  in  which  Listerism  has  worked  the 
greatest  change  have  been  those  in  which,  prior  to  its  introduction,  the  principles 
of  surgical  hygiene  have  been  the  least  attended  to.  Safety  from  wound- poison- 
ing lies  in  either  plan,  the  greatest  security  being  obviously  in  the  combination  of 
both.  We  should  like  to  call  attention,  but  have  not  space  to  do  more,  to  Mr. 
T\  ells' s  most  judicious  remarks  upon  the  administration  of  stimulants  after  opera- 
tion. We  should  also  like  much  to  have  Mr.  Wells's  opinion  of  Battey's  opera- 
tion ;  for  the  sake  of  this,  we  could  even  have  spared  Lord  Selborne's  calculations, 
which  we  fancy  we  have  heard  before. 

And  with  respect  to  uterine  tumours,  Mr.  Wells  omits  to  answer  what  seems  to 
us  the  vital  question  with  regard  to  them :  what  are  the  circumstances  which 
render  the  abdominal  removal  of  a  uterine  fibroid  justifiable  ?  There  is  one  vast 
difference  between  these  growths  and  ovarian  cysts.  Ovarian  tumours  tend  to 
death  :  uterine  tumours,  as  a  rule,  do  not.  Hence  the  rule  of  practice  must 
greatly  differ.  We  should  like  much  to  have  heard  what  Mr.  Wells  thinks  on 
this  point.— Med.  Times  and  Gazette,  Aug.  3,  1878. 

Catgut  Sutures  in  Ccesarean  Section. 
Dr.  E.  W.  Jenks,  of  Detroit,  Michigan,  in  an  article  on  the  use  of  catgut 
sutures  in  Cassarean  section  (Archives  de  Tocologie)  says  :  ' '  Theoretically  catgut  is 
the  best  material  on  account  of  its  unhurtful  character  and  prompt  absorption,  but 
practically  it  will  continue  to  be  an  indifferent  suture  until  some  one  has  discovered 
a  method  of  keeping  it  well  secured,  for  the  warmth  and  humidity  of  the  perito- 
neal cavity  relaxes  and  opens  the  common  surgeon's  knot.  I  have  employed  it 
in  a  case  of  ovariotomy  to  tie  the  vessels,  and  the  post-mortem  examination  has 
but  too  well  proven  the  truth  of  my  last  assertion.  I  have  likewise  used  it  during 
the  past  few  months  on  several  occasions  in  plastic  operations  in  the  vicinity  of  the 
vagina,  and,  in  each  case,  expecting  that  it  would  keep  the  parts  in  apposition,  the 
result  was  nevertheless  a  complete  failure.  Now,  since  the  only  object  of  uterine 
sutures  in  Cassarean  section  is  to  maintain  the  incised  partition  walls  in  contact,  to 
prevent  liquids  from  entering  into  the  uterine  and  peritoneal  cavities,  such  mate- 
rial only  should  be  employed  in  cases  of  this  kind  as  can  be  invariably  relied 
upon. 

"I  see  by  an  article,  written  in  an  English  journal  by  a  writer  whose  name  I 
cannot  now  recall,  that  he  claims  to  have  invented  a  way  of  making  a  knot  with 
gut  cord,  which  would  neither  slip  nor  untie.  I  have  not  tried  his  method,  nor 
am  I  disposed,  on  account  of  my  previous  experience,  to  make  my  first  applica- 


586 


Progress  of  the  Medical  Sciences. 


[Oct. 


tion  with  it  in  the  abdomen.  It  would  appear  that  up  to  the  present  time  we  are 
possessed  of  nothing  superior  for  uterine  sutures  to  silver  wire  and  silk  thread,  and 
of  those  two  the  former  is  probably  the  best. 

"  As  to  the  little  confidence  we  can  have  in  gut  cord  for  uterine  sutures,  I  would 
refer  you  to  the  Transactions  of  the  London  Obstetrical  Society,  vol.  xvii.,  where 
a  case  of  Cassarean  section  is  recorded  by  Dr.  Oswald  ;  the  operation  was  made 
by  Dr.  Routh,  who  closed  the  wounds  of  the  uterus  with  sutures  of  the  best  gut 
cord,  firmly  tying  the  same.  The  patient  lived  three  days  after  the  operation. 
The  post-mortem  examination  revealed  that  the  knot  was  relaxed  and  opened,  so 
that  a  quantity  of  liquid  escaped  into  the  abdominal  cavity,  poisoning  the  patient. 

"  The  opinion  of  Dr.  Routh  coincides  with  that  of  the  majority  of  his  colleagues, 
that  had  he  used  sutures  of  metal  or  silk,  instead  of  the  gut,  he  could  have  saved 
the  life  of  the  patient.  Dr.  Meadows  adds,  that  it  was  undoubtedly  the  second 
case  in  which  death  could  be  attributed  to  the  use  of  gut  cord  sutures  on  the  ute- 
rus."— Michigan  JSIedical  Neics,  June  10,  1878. 


MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 

Examination  of  Seminal  Stains  found  on  the  Wooden  Floor  of  a  Room. 

Dr.  Gallard,  in  an  article  in  the  Gazette  des  IJopitaux,  1878,  No.  44,  arrives 
at  the  following  conclusions:  1.  The  examination  of  these  stains  may  give  as 
authentic  results  as  that  of  stains  on  linen  or  clothes.  2.  If  the  semen  form  a 
sort  of  slightly  adherent  varnish  on  the  floor,  the  flakes  of  which  are  easily  sepa- 
rated, the  examination  is  less  difficult  than  when  it  has  to  do  with  linen  or  cloth, 
as  it  is  only  needful  to  dissolve  the  dried  semen  in  a  little  distilled  water.  But  if 
the  semen  have  soaked  into  the  wood,  a  little  water  must  be  placed  in  contact  with 
the  stain  for  a  time,  and  then  the  wood  must  be  scraped  with  a  scalpel. — London 
Medical  Record,  Aug.  15,  1878. 

Malformations  of  the  Hymen  in  their  Relation  to  Legal  Medicine. 
Under  this  title,  Dr.  Delens  has  published  three  cases  taken  from  his  medico- 
legal practice.  The  first  is  that  of  a  girl  15f  years  of  age,  who  was  the  victim 
several  years  ago  of  repeated  assaults,  was  even  afflicted  with  vulvitis  and  vagi- 
nitis, but  yet  not  deflorated.  The  integrity  of  the  hymen  in  this  ease  was  ex- 
plained by  its  formation.  It  was  thickened  to  at  least  1  millimetre  (.04  inch), 
and  was  pierced  by  a  hole  only  1  millimetre  in  diameter,  and  was  as  resistant  as 
an  imperforate  hymen.  From  the  absence  of  laceration  it  may  be  inferred  that 
repeated  violence  was  not  exercised.  The  two  other  cases  are  very  rare  examples 
of  biperforate  hymen.  In  one  of  these  cases  the  two  openings  were  not  more  than 
two  centimetres  (.8  inch)  in  diameter;  in  the  other,  they  were  seven  or  eight 
millimetres  by  three  or  four.  In  cases  of  this  kind  the  median  and  solid  portion 
is  an  obstacle  to  defloration,  which  is  the  more  serious  as  the  openings  are  smaller. 
The  expert  should  take  this  circumstance  into  account. — London  Medical  Record, 
Aug.  15,  1878. 


1878.] 


587 


AMERICAN  INTELLIGENCE. 

ORIGINAL  COMMUNICATIONS. 

Femoral  Hernia  Strangulated  on  its  First  Descent;  Operation;  Re- 
covery.   By  G.  H.  Balleray,  M.D.,  of  Paterson,  New  Jersey. 

I  was  called  March  19th,  1877,  to  see  Mrs.  K.,  German,  aged  64,  and 
mother  of  several  children.  Not  being  able  to  see  her  at  once,  I  requested 
my  friend,  Dr.  James  C.  Amiraux,  to  visit  the  patient  for  me.  Upon  ex- 
amination, he  found  her  suffering  from  strangulated  femoral  hernia;  and 
he  obtained  the  following  history  :  On  the  morning  of  the  same  day  the 
patient  was,  as  usual,  performing  her  household  duties,  when,  in  lifting  a 
scuttle  of  coal,  she  felt  a  sudden  and  sharp  pain  in  the  groin,  and  on  ex- 
amination, discovered  a  swelling  in  that  region.  The  pain  increased  in 
severity,  notwithstanding  the  administration  of  "  hot  drops,"  "  pain 
killer,"  etc.,  and  after  a  few  hours  vomiting  ensued. 

When  seen  by  Dr.  Amiraux,  at  2  P.  M.,  she  was  suffering  severe  pain, 
and  had  vomited  several  times.  He  endeavoured  to  reduce  the  hernia  by 
taxis,  but  after  a  faithful  trial  of  over  an  hour's  duration,  found  it  im- 
practicable. Not  wishing  to  assume  alone  the  responsibility  of  administer- 
ing an  anaesthetic,  as  the  patient  had  been  suffering  for  some  time  from  a 
chronic  bronchial  affection,  Dr.  A.  requested  me  to  visit  her  with  him. 
I  did  so,  and  tirst  attempted  the  reduction  of  the  hernia  without  anaesthe- 
sia, but  meeting  with  no  better  success  than  had  Dr.  A.  previously,  I 
placed  the  patient  under  the  influence  of  ether,  when  another  cautious 
and  persevering,  but  ineffectual,  attempt  at  reduction  by  taxis  was  made 
by  both  Dr.  A.  and  myself.  1  then  informed  the  relatives  of  the  patient 
that  an  operation  would  in  all  probability  be  required,  and  having  requested 
Dr.  Amiraux  to  administer  a  large  enema  of  soap  and  water,  to  clear  out 
the  large  intestine,  and  afterwards  a  hypodermic  injection  of  one-third  of 
a  grain  of  morphia,  I  left,  with  the  understanding  that  I  would  return  at 
7.30  P.  M.,  prepared  to  operate,  should  another  attempt  at  reduction  by 
taxis,  while  the  patient  was  under  the  influence  of  an  anaesthetic,  fail. 

At  7.30  P.  M.  I  found  the  patient  extremely  averse  to  an  operation, 
but  her  consent  was  finally  obtained.  She  was  anaesthetized,  and  another 
attempt  at  reduction  by  taxis  was  made  by  Dr.  Marsh,  Dr.  Terriberry, 
and  myself ;  but  without  success.  I  then  proceeded  to  operate  in  the  pre- 
sence of  Drs.  Marsh,  Seal,  Amiraux,  and  C.  Terriberry.  Having  cut 
down  to  the  sac,  this  was  cautiously  opened,  when  about  an  ounce  of 
brownish-yellow  fluid  escaped,  and  a  portion  of  deeply-congested  intestine 
came  into  view,  which  was  so  tightly  grasped  by  the  edges  of  the  saphen- 
ous opening,  which  it  overlapped  in  every  direction,  that  it  was  exceed- 
ingly difficult  to  insinuate  the  hernia  knife  beneath  the  stricture  without 
incurring  serious  risk  of  wounding  the  bowel ;  with  care  and  patience, 
however,  this  obstacle  was  overcome,  and  the  stricture  divided  to  the  ex- 
tent of  about  three  lines.  I  then  attempted  to  return  the  protruded  intes- 
tine, but  did  not  succeed.    At  the  suggestion  of  Dr.  Marsh,  the  needle  of 


588 


American  Intelligence. 


[Oct. 


a  hypodermic  syringe  was  passed  into  the  intestine,  and  about  three  drachms 
of  bloody,  frothy  serum  withdrawn  ;  this  diminished,  to  some  extent,  the 
tension  of  the  hernial  tumour,  but  not  sufficiently  to  allow  of  its  reduction. 
I  now  requested  Dr.  Terriberry  to  protect  the  intestine  with  his  hand,  and 
at  the  same  time  to  gently  draw  it  downwards,  while  I  carefully  passed  a 
director  beneath  the  falciform  border  of  the  fascia  lata,  and  divided  that 
structure  with  a  probe-pointed  bistoury,  to  the  extent  of  over  half  an 
inch  ;  after  which,  reduction  was  easily  accomplished.  So  tight  was  the 
stricture,  and  so  deep  the  congestion,  that  the  intestine  was  perfectly 
black;  but  as  it  still  retained  its  polish,  and  improved  in  appearance  after 
division  of  the  stricture,  it  was  returned.  The  wound  was  closed,  a  pad 
and  bandage  applied,  and  the  patient  put  to  bed,  and  only  sufficient  morphia 
given  to  allay  the  harassing  cough  witli  which  she  was  troubled. 

The  sutures  were  removed  on  the  morning  of  the  fourth  day,  and  the 
wound  was  dressed  with  lint  saturated  with  a  lotion  composed  of  carbolic 
acid,  glycerine,  and  water.  An  erysipelatous  blush  showed  itself  about 
the  wound  on  the  fifth  day,  but  subsided  in  the  course  of  two  or  three  days. 
The  bowels  were  moved  by  an  enema  on  the  sixth  day.  On  the  eighth 
day  several  petechial  spots  appeared  upon  the  legs,  thighs,  abdomen,  chest 
and  arms  ;  the  pulse  became  frequent  and  feeble,  and  there  was  a  tendency 
to  diarrhoea;  but  under  the  influence  of  iron,  quinia,  concentrated  liquid 
nourishment,  and  an  increase  in  the  amount  of  stimulants  which  it  had 
been  found  necessary  to  give  from  the  first,  the  patient  gradually  improved  ; 
the  spots  faded  away  in  the  course  of  five  or  six  days,  and  at  the  end  of 
the  third  week  perfect  convalescence  was  established. 

The  points  of  interest  in  this  case  are,  first,  the  occurrence  of  strangu- 
lation upon  the  first  descent  of  the  hernia ;  second,  the  seat  of  the  stric- 
ture, and  the  extent  to  which  it  was  necessary  to  divide  it,  before  reduction 
of  the  hernia  could  be  accomplished. 

As  regards  the  first  point,  it  may  be  stated  that  in  cases  in  which 

strangulation  occurs  upon  the  first  descent  of  a  femoral  hernia,  the  danger 

is  greater,  and  more  prompt  measures  for  its  relief  are  required  than  when 

a  similar  accident  occurs  in  the  case  of  a  hernia  of  long  standing.  TN'ith 

reference  to  this  point,  Mr.  Birkett,  the  author  of  the  article  on  hernia  in 

Holmes'  System  of  Surgery,  says  : — 

' '  The  mortality  arising  in  cases  of  strangulated  crural  hernia  of  all  kinds  is 
very  large  ;  but  in  those  where  the  bowel  becomes  strangulated  on  the  first  de- 
scent, the  death-rate  is  the  largest.  The  experience  of  a  large  number  of  these 
cases  teaches  that  the  bowel  should  be  liberated  as  soon  as  possible,  and,  if  the 
taxis  be  not  successful  when  the  patient  is  fully  under  the  influence  of  chloro- 
form, that  the  cutting  operation  should  not  be  delayed  a  moment." 

In  this  case,  had  the  operation  been  delayed  until  the  following  morn- 
ing, the  bowel  would  have  been  gangrenous,  and  in  all  probability  the 
patient  would  have  died.  The  stricture  was  formed  by  the  dense,  unyield- 
ing structures  surrounding  the  saphenous  opening.  The  division  of  the 
femoral  (Hey's)  ligament  did  not  liberate  the  intestine,  and  it  was  only 
after  free  division  of  the  falciform  process  of  the  fascia  lata  that  the  bowel 
could  be  returned.  Gimbernat's  ligament  played  no  part  in  the  production 
of  the  strangulation. 


1878.] 


Domestic  Summary. 


589 


DOMESTIC  SUMMARY. 

Induction  of  Premature  Labour  in  the  Albuminuria  of  Pregnancy. 
In  a  short  article  in  the  American  Journal  of  Obstetrics  (July,  1878),  Dr. 
Fordyce  Barker  earnestly  advocates  the  non-induction  of  premature  labour 
in  the  albuminuria  of.  pregnancy  until  after  appropriate  treatment  has  been 
thoroughly  and  perseveringly  tried  without  success  for  the  removal  of  symptoms 
of  albuminuria  of  so  grave  a  character  that  there  is  strong  probability*  that  their 
continuance  would  result  in  the  death  of  the  patient. 

Ireatment  of  Eczema  Rubrum  by  means  of  Glycerole  of  the  Subacetate  of  Lead. 

The  use  of  glycerole  of  the  subacetate  of  lead  as  an  application  in  chronic 
eczema  rubrum  was  first  brought  prominently  to  the  notice  of  the  profession  by 
Mr.  Balmanno  Squire,  of  London.1  But  up  to  the  present  time  this  plan  of 
treatment  has  not  attracted  as  much  attention,  in  this  country  at  least,  as  it  de- 
serves. Drs.  Duhrixg  and  Van  Harlixgex  have  been  using  the  glycerole 
in  their  dispensary  practice  for  tlie  past  six  months,  and  the  results  which  they 
have  obtained  (Phila.  Med.  Times,  Aug.  3,  1878)  are  of  so  favourable  a  char- 
acter as  to  suggest  a  further  and  more  extensive  use  of  this  remedy  in  the  class 
of  diseases  to  which  it  is  applicable. 

For  an  account  of  the  theory  of  action  of  the  glycerole,  reference  may  be  made 
to  Mr.  Squire's  papers.    The  formula  which  he  suggests  is  as  follows  : — 

Acetate  of  lead,  5  parts  ; 

Litharge,  3^  parts ; 

Glycerine,  20  parts,  by  weight. 
Mix,  and  expose  for  some  time  to  a  temperature  of  350°  F.    Filter  through  a 
hot- water  funnel.    The  clear  viscid  fluid  resultant  contains  120  grains  of  the 
subacetate  of  lead  to  the  ounce.    It  is  used  as  a  stock  from  which  the  prepara- 
tions employed  are  made  by  dilution  with  simple  glycerine. 

The  results  obtained  in  their  series  of  cases  and  also  in  others  coming  under 
their  observation  during  the  last  six  months,  led  to  the  following  conclusions.  In 
glycerole  of  the  subacetate  of  lead  we  have  a  valuable  addition  to  the  therapeu- 
tics of  certain  forms  of  chronic  eczema,  particularly  eczema  rubrum  of  the  lower 
extremities.  It  is  most  useful  in  those  cases  where  the  affection  is  extensive,  of 
a  dusky  hue.  accompanied  by  much  weeping,  oozing,  and  infiltration  of  the  skin, 
together  with  swelling  and  oedema  of  the  subcutaneous  tissues,  and  a  full  and 
varicose  condition  of  the  venous  circulation.  In  such  cases  glycerole  of  the  sub- 
acetate of  lead,  used  with  diligence,  and  followed  by  careful  bandaging,  consti- 
tutes a  remedy  of  the  highest  value. 

Glycerole  of  the  subacetate  of  lead  has  not,  however,  any  anti-pruritic  quali- 
ties, excepting  in  so  far  as  it  may  reduce  the  oedema  which  sometimes  appears  to 
give  rise  to  pruritus.  Nor  has  it  any  resolvent  effect  upon  infiltration  of  the  more 
superficial  layers  of  the  integument.  In  this  respect  it  fails  just  in  those  cases 
and  at  that  stage  of  eczema  rubrum  where  the  skin  is  no  longer  acutely  inflamed, 
but  is  thickened,  indurated,  and  pruriginous ;  in  other  words,  where  ordinarily 
the  preparations  of  tar  and  potash  are  most  useful. 

Glycerole  of  the  subacetate  of  lead  fails,  moreover,  to  exert  a  favourable  influ- 
ence in  those  cases  of  eczema  rubrum  where  the  disease  shows  itself  in  numerous 
variously- seized  superficial  patches,  and  where  the  deeper  layers  of  the  skin  do 


1  Medical  Times  and  Gazette,  1876,  vol.  i.,  March  18  and  25,  and  Essays  on  the 
Treatment  of  Skin  Disease,  No.  2  (second  edition),  London,  J.  &  A.  Churchill,  1S78. 


590 


American  Intelligence. 


[Oct.  1878. 


not  appear  to  be  affected.  With  regard  to  its  effect  in  the  vesicular  and  squa- 
mous varieties  of  eczema,  this  is  not  satisfactory,  and  it  is  less  favourable  in  pro- 
portion as  the  case  departs  from  the  typical  form  of  eczema  rubrum. 

Occasionally  the  glycerole  is  found  to  disagree  with  the  skin.  This,  however, 
does  not  often  happen,  at  least  not  nearly  so  often  as  in  the  case  of  glycerine. 

Ligation  of  the  Lingual  Artery  near  its  Origin,  as  a  Preliminary  Procedure  in 
the  Extirpation  of  Cancerous  Disease  of  the  Tongue. 

Dr.  George  F.  Shrady,  Surgeon  to  the  Presbyterian  Hospital,  Xew  York, 
reports  {Med.  Jiecord,  Sept.  14,  1878)  a  case  of  epithelioma  of  the  tongue  in- 
which  the  lingual  artery  was  ligated  near  its  origin,  as  a  preliminary  procedure  in 
the  operation  for  extirpation  of  the  disease,  and  he  submits  the  following  conclu- 
sions to  which  he  has  been  led  by  a  careful  consideration  of  the  case  : — 

1.  In  cancer  of  the  tongue,  whenever  it  is  possible,  the  disease  should  be  re- 
moved through  the  mouth. 

2.  Ligation  of  the  lingual  artery  is  a  very  necessary  .preliminary  to  such  a 
procedure. 

3.  Ligation  of  the  lingual  artery,  if  performed  at  all,  should  be  near  the  origin 
of  the  vessel,  as  by  that  means  the  whole  of  the  blood-supply  of  one  side  of  the 
tongue  is  completely  cut  off. 

4.  The  operation  of  ligation  of  the  lingual  artery,  even  in  that  situation,  is  less 
difficult  than  the  securing  of  the  vessel  in  the  wound  during  the  operation  of  ex- 
tirpation of  the  tongue,  and  when  there  is  free  hemorrhage  deep  in  the  mouth. 

5.  The  distance  between  the  external  carotid  and  the  point  of  ligature  is 
sufficient  for  the  foundation  of  a  firm  clot  and  the  prevention  of  secondary 
hemorrhage. 

6.  The  use  of  the  scissors  and  the  knife  places  the  wound  in  a  condition  more 
favourable  for  rapid  healing  than  when  the  ecraseur  or  any  variety  of  cautery  is 
used. 

7.  Ligation  of  the  lingual  may  have  a  tendency  to  retard  the  return  of  the 

disease. 

The  Unequal  Length  of  Normal  Limbs  shown  by  Measurement  of  the  Skeleton. 

A  good  deal  of  attention  has  been  recently  directed  to  the  inequality  in  the 
length  of  the  lower  limbs,  and  a  number  of  observations  have  been  made  by  Drs. 
Cox  and  Wright  on  the  living  body  to  demonstrate  this.  Dr.  Jokx  B.  Roberts 
has  recently  (Phila.  Med.  Times,  Aug.  3,  1878)  made  accurate  measurements 
of  the  femora  and  tibise  of  eight  skeletons  in  the  museum  of  the  Jefferson  ^Medi- 
cal College  and  elsewhere,  in  the  following  manner.  He  took  an  ordinary  gradu- 
ated yard-stick,  and  had  a  piece  of  iron  fixed  to  one  end  at  a  right  angle,  while 
up  and  down  the  stick  there  played  a  slide  with  a  similar  piece  of  iron  also  at  a 
right  angle.  This  was  employed  just  as  a  shoemaker  uses  his  rule  to  obtain  the 
length  of  his  customer's  foot.  The  results  show  an  inequality  in  each  skeleton 
varying  from  an  eighth  to  three-quarters  of  an  inch. 

In  commenting  on  these  results  Dr.  Roberts  says  :  "  These  figures  show  con- 
clusively to  my  mind  the  folly  of  endeavouring  to  make  the  limbs  of  equal  length 
after  one  of  them  has  sustained  fracture ;  it  may  be  possible  if  the  patient  hap- 
pens to  break  the  long  leg,  but  what  will  be  the  result  if  he  have  this  accident 
occur  to  the  one  already  half  an  inch  shorter  than  its  fellow  ?  Is  the  surgeon  to 
continue  his  extension  until  both  legs  reach  the  same  mark  on  his  graduated  tape  ? 
Especially  is  this  to  be  deprecated  when  we  recollect  the  probability  of  his  meas- 
urements differing  every  day  on  account  of  the  difficulty  of  applying  the  tape  to 
exactly  the  same  spot  on  each  side." 


INDEX. 


A. 

Abelcs,  glycogen,  537 
Abscess,  hepatic,  opening  into  the  luno-, 
259 

 ,  pelvic  and  abdominal,  SI 

Accommodation,  muscle,  of,  and  its  mode 

of  action,  349 
Aconite,  opium,  and  belladonna,  compa- 
rison of,  539 
Adams-,  Dupuytren's  contraction  of  the 
fingers,  569 

 ,  poro-plastic  felt  jacket,  576 

Adelmaun,  extirpation  of  scapula,  275 
Albuminuria  of  pregnancy,  induction  of 

premature  labour  in,  589 
Alkalies,  action  of,  on  globular  richness  of 
blood, 367 

Althaus,  relations  between  progressive 
ataxy  and  spasmodic  spinal  paralysis, 
338 

American  Gynaecological  Society's  Trans- 
actions, notice  of,  482 
Ancona,  exophthalmic  goitre  caused  by 

galvanization  of  the  sympathetic,  256 
Andrews,  presystolic  murmurs,  199 
Aneurism  of  the  subclavian,  amputation 
at  shoulder-joint,  206 

 ,  innominate,  diagnostic  value  of 

radial  pulse  in,  258 

 of  aorta,  electro-puncture  in,  274 

 ,  and  of  innominate,  sub- 
clavian and  carotid,  570 
Annandale,  strychnia  in  writer's  palsy,  254 
Anstie,  Use  of  Wines,  notice  of,  243 
Antiseptic  method,  application  of,  where 

sepsis  is  present,  263 
Aorta,  band  across,  247 
Archer,  band  across  aorta,  247 
Arlt,  Injuries  of  the  Eye,  notice  of,  232 
Arsenic,  urethritis  following  use  of,  270 
Arthritis  secondary  to  acute  myelitis,  572 
Asthma,  subcutaneous  injection  of  arsenic 
in,  25(5 

Ataxy,  progressive,  and  spasmodic  spinal 
paralysis,  33 S 

Atlee,  laparotomy  in  extra-uterine  preg- 
nancy. 321 

Aufreeht,  tetanus,  261 

Axilla,  injury  to,  during  reduction  of  hu- 
merus, 572 

B. 

Bacteria  not  essential  to  infection,  495 
Baker,  synovial  cysts  in  leg  in  connection 
with  disease  of  knee-joint,  207 


Balleray,  femoral  hernia  strangulated  in 

its  first  descent,  587 
Balz,  paracotoin  in  cholera,  553 
Barker,  anomalous  obturator  artery,  269 
 ,  induction  of  premature  labour  in 

albuminuria  of  pregnancy,  589 
Barwell,  aneurism  of  aorta,  innominate, 

subclavian,  and  carotid,  570 
Battey's  operation    for  dysmenorrhea, 

297 

 fibroid  of  uterus,  36 

 ,  is  there  a  proper  field 

for?  489 

Beard,  atrophy  of,  88 

Belladonna,  opium,  and  aconite,  compari- 
son of,  539 

Berger,  gummy  tumours  of  conjunctiva, 
578 

Bernard  and  his  Physiological  Works,  re- 
view of,  161 

Bibliographical  Notices — 

 American  Gynaecological  Society's 

Transactions,  482 

 Anstie,  Wines  in  Health  and  Dis- 
ease, 243 

 Arlt,  Injuries  of  the  Eye,  232 

 Billings,  Report  on  Heating  and 

Ventilating,  523 
 Busey,  Congenital  Occlusion  and 

Dilatation  of  Lymph  Channels,  527 
 Duhring,  Atlas  of  Skin  Diseases, 

232,  531 

 Fialla,  Cure  of  Congenital  Cataract, 

227 

 Flint,  Source  of  Muscular  Power, 

215 

 Gerrish,  Prescription  Waiting,  244 

 Graefe's  Life  and  Works,  Notice  of, 

216 

 Gray's  Anatomy,  532 

 Green,  Pathology  of  Pulmonary 

Consumption,  524 

 Hirschberg,  Contributions  to  Prac- 
tical Ophthalmology,  510 

 Hutchinson,  Illustrations  of  Clini- 
cal Surgery,  230 

 Jones,  Aural  Surgery,  234 

.  Liverpool  and  Manchester  Medical 

and  Surgical  Reports,  495 

 Logan,  Physics  of  the  Infectious 

Diseases,  529 

 Massachusetts,    State    Board  of 

Health  Report,  512 

 Mauthner,  Lectures  on  Ophthalmo- 
logy, 507 


592 


Index. 


Bibliographical  Notices — 

 Mortuary  Experience  of  Mutual 

Life  Insurance  Company,  240 

 New  York  State  Medical  Society's 

Transactions,  245 

Obstetrical  Society's  Transactions, 


207 


Ogston,  Medical  Jurisprudence.  222 
 Osier,  Pathological  Report  of  Mon- 
treal General  Hospital,  238 

 Parkin,  Antidotal   Treatment  of 

Disease,  528 

Pittsburgh  Board  of  Health  Report, 


244 


Carrescia,  hepatic  abscess  opening  into  the 

lunar ;  259 
Cataract,  cure  of  congenital,  227 
Catsrut  sutures,  565 

Cerebro-spinal  meningitis,  epidemic.  519 
Chauvel,  lymphadenoma  with  retinal  he- 
morrhages, 264 
Cholecvstotomv  in  dropsy  of  gall-bladder, 

565  * 
Chloral,  butyl,  .540 

Chloroform  in  labour,  caution  in  use  of, 

485 

Chloroma,  561 
Cholera,  paracotoin  in,  553 


Politzer,  Occurrence  of  Danger  in  Circulation,  effect  of  posture  on  peripheral, 


Course  of  Disease,  526 

Rai  Ram  Narain  Dass,  Lateral  Li- 


thotomy Operations,  500 

Saint  Bartholomew's  Hospital  Re- 


ports, 199 

Sehweigger,  Handbook  of  Ophthal- 


mology, 245 
 State  Medical  Society's  Transac- 
tions, 245,  516 

 Subject-Catalogue  of  the  Library  of 

the  Surgeon-General's  Office.  Abbre- 
viations to  be  used  in,  533 

Tuke,  Insanity  in  Ancient  and  Mod- 


ern Life,  236 

Ziemssen,  Practice  of  Medicine,  503 


Biddle,  experiments  on  lead  carbonate.  439 

Billings,  Report  on  Heating  and  Ventila- 
tion, notice  of,  523 

Bismuth,  subnitrate  of,  538 

Bladder,  inversion  of,  415 

Blood,  action  of  drugs  on  globular  richness 
of,  367 

Bloodvessels,  union  of  divided,  262 
Boettger,  misuse  of  bromide  of  potassium. 
541 

Bogue,  tracheotomy  in  diphtheria,  298 
Bladder,  ergotin  in  diseases  of,  567 

 ,  inversion  of,  445 

Bradford,  action  of  drugs  on  globular 

richness  of  blood,  367 
Brain,  lesions  of  base  of,  125 
 .  sphv^mographic  experiments  upon, 

103 

Brieger,  action  of  purgatives,  538 
Brigliam,  excision  of  scapula  and  head  of 

humerus,  296 
Bromide  of  potassium,  misuse  of,  541 
Browne,  The  Throat  and  its  Diseases,  re- 
view of,  451 
Bull,  pathology  of  orbital  cellulitis,  112 

 ,  syphilis  of  conjunctiva,  405 

Busey,  Congenital  Occlusion  and  Dilata- 
tion of  Lymph  Channels,  notice  of,  527 
Butyl  chloral,  .540 

Byrne,  amputation  of  cervix  uteri,  4S2 


Callender,  diseases  of  diaphragm,  551 

 ,  dislocation  of  n~useles,  573 

Cameron,  pustular  eruption  in  pvasmia, 

559 
Cancer,  560 

Carbolic  acid,  properties  of,  24S 
 ,  sulphuric  acid  as  an  anti- 
dote to,  290 
Carotid,  common,  ligation  of,  44S 


574 

Clarke,  Visions,  review  of,  475 
Clavicle,  exsection  of,  275,  562 
Cleft  palate  in  Negro,  296 
Cloetta,  action  of  piiocarpin  and  cotoin, 
544 

Colley,  rheumatoid  inflammation  of  joints 

in  women,  2S4 
I  Colour-blindness,  579 

 ,  review  on,  466 

Conjunctiva,  gummy  tumour  of,  578 

 .  syphilis  of,  4<J5 

j  Connecticut  Medical  Society's  Transac- 
tions, notice  of,  522 
!  Consumption,  contagiousness  of,  145 
Cornea,  calcareous  tflm  of,  279 
Corpus  luteum  of  pregnancy,  Dalton  on, 
4S3 

Coto,  uses  of,  544 
Cotoin,  action  of,  544 
Cutler,  action  of  drugs  on  globular  rich- 
ness of  blood,  367 
Cutter,  galvanism  in  treatment  of  uterine 

fibroids,  50 
Cysts,  synovial,  in  leg,  in  connection  with 

knee-joint,  207 
Czerny,  laparotomy  under  antiseptic  me- 
thod, 268 

D. 

Dalton,  corpus  luteum,  483 
Delboeuf,  colour-blindness,  466 
Delens,  malformations  of  hymen,  5S6 
Demme.  action  of  piiocarpin,  543 
De  Rossett.  muscle  of  accommodation  and 

its  mode  of  action,  349 
Desenne,  new  parasitic  disease  of  hair,  556 
Diabetes  insipidus  cured  by  ergot,  259 
Diaphragm,  diseases  of,  551 
Diarrhoea,  cold  water  enemata  in,  133 
Duhring.  Atlas  of  Skin  Diseases,  notice  of, 
232.  531 

 ,  atrophy  of  beard,  88 

!  ,  case  ot  xeroderma,  424 

 .  glycerole  of  subacetate  of  lead 

in  eczema  rubrum,  589 
|  Dujardin-Beaumetz,   electro-puncture  in 

aneurism  of  aorta,  274 
Duncan,  revolution  of  fcetal  head  in  pass- 
ing through  contracted  brim,  580 

 — ,  traction  of  lower  jaw  in  head-last 

cases,  282 

Dureau,  injections  of  nitrate  of  silver  in 

sciatica,  259 
Dysinenorrhoea,  membranous.  211 
 ,  radical  treatment  of.  493 


Index. 


593 


Eclampsia,  puerperal,  483 
Eczema,  coloured  exudation  in,  260 
 ,  rubrum,  glycerole  of  subacetate  of 

lead  in,  589 
Education,  higher  medical,  review  of,  174 
Embolism,  sudden  death  by,  549 
Emmet,  congenital  absence  and  accidental 

atresia  of  vagina,  490 
Engelmaun,  hystero-neurosis,  491 
Enterotomy,  268,  565 
Erb,  spasmodic  spinal  paralysis  in  infants, 

254 

Erythromelalgia,  17 
Esmarch,  cancer,  560 
Eustachian  tube,  function  of,  536 


Eabre,  colour-blindness,  578 

Face  presentations,  etiology  of,  581 

 ,  severe  gunshot  wound  of,  92 

 ,  unilateral  atrophy  of,  437 

Faris,  partial  excision  of  spleen,  296 
Fevers,  wound-,  septic  and  aseptic,  557 
Fialla,  Cure  of  Congenital  Cataract,  no- 
tice of,  227 
Filtration,  513 

Fingers,  Dupuytren's  contraction  of,  569 

 ,  vaso-motor  and  trophic  affection 

of,  431 

Flint,  Source  of  Muscular  Power,  notice 
of,  214 

Forbes,  Harvey  and  the  transit  of  the 
blood,  139 

Franck,  diagnostic  value  of  radial  pulse  in 

innominate  aneurism,  258 
Frew,  spaying  for  severe  dysmenorrhoea, 

297 

Fronmuller,  uses  of  coto,  544 
G. 

Gall-bladder,  cholecystotomy  in  dropsy  of, 
565 

Gallard,  examination  of  seminal  stains, 
586 

Galvanism  in  treatment  of  uterine  fibroids, 
50 

Gastro-hysterotomy,  statistics  of,  68 

Gastrotomy,  563 

Gay,  varicose  ulcers,  577 

Genzmer,  treatment  of  hydrocele,  567 

Georgia  Medical  Society's  Transactions, 
notice  of,  516 

Gibney,  diagnosis  of  hip  disease,  387 

Glycogen,  537 

Goitre,  death  from,  548 

 ,  exophthalmic,  cured  by  galvaniza- 
tion of  the  sympathetic,  256 

Goodell,  spaying  for  fibroid  tumours  of  the 
womb,  36 

 ,  vaginal  ovariotomy,  488 

Gout,  spinal,  253 

Graefe's  Life  and  Works,  notice  of,  216 
Gray's  Anatomy,  notice  of,  532 
Green,  Pathology  of  Pulmonary  Consump- 
tion, notice  of,  524 
Gubler,  subnitrate  of  bismuth,  538 
Gundrum,  extirpation  of  scapula,  98 
Gunshot  wound  without  perforation  of 
skin,  290 


H. 

Ha?mophilia,  pathology  of,  253 
Hair,  new  parasitic  disease  of,  556 
Hall,  acute  inversion  of  uterus,  291 
Hardy,  tartar  emetic  in  pneumonia,  548 
Hare-lip  in  Negro,  297 
Harris,  laparotomy  in  extra-uterine  preg- 
nancy, 321 

 ,  statistics  of  gastro-hysterotomy,  68 

Hartmaun,  function  of  Eustachian  tube, 
536 

Harvey  and  the  transit  of  the  blood,  138 
Hattenhoff,  causes  of  myopia,  281 
Haussmann,  treatment  of  sore  nipples,  284 
Hayes,  iodoform  in  eye  diseases,  578 
Head,  revolution  of  foetal,  in  passing 

through  contracted  brim,  580 
Head-last  cases,  traction  of  lower  jaw,  282 
Heat  to  skin,  action  of,  upon  circulation, 

251 

Heinklein,  urticaria  following  salicylate 

of  soda,  260 
Hepatic  abscess  opening  into  lung,  259 
Hemorrhage,  dilatation  of  cervix  uteri  for 

arrest  of,  484 
Hernia,  femoral,  in  which  an  anomalous 

obturator  artery  was  divided,  269 
 ,  femoral,  strangulated  in  its  first 

descent,  587 
 ,  use  of  testicle  in  cure  of  inguinal, 

443 

Hervieux,  puerperal  poisoning,  283 
Hip,  disarticulation  of,  272 

 disease,  diagnosis  of,  387 

Hirschberg,  Contributions  to  Practical 
'  Ophthalmology,  notice  of,  516 
Hofmann,  pistol  shot  wound  without  per- 
foration of  skin,  290 
Holden,  aneurism  of  subclavian,  amputa- 
tion at  shoulder-joint,  206 

,  Is  consumption  contagious?  145 


Huber,  chloroma,  561 
Hughes,  epidemic  cerebro-spinal  menin- 
gitis, 519 

Humerus,  epicondylar  fractures  Of,  278 

 ,  injury  to  axilla  during  reduction 

of,  572 

Hutchinson,  Illustrations  of  Clinical  Sur- 
gery, notice  of,  230 
 ,  intestinal  obstruction,  553 


Hydatid  of  pelvis  simulating  retro  uterine 

haematocele,  289 
Hydrarthrosis  of  knee,  intermittent,  279 
Hydrocele  treated  by  electricity,  272 
 '   treated  by  incision  antisepti- 


cally,  567 
Hymen,  malformations  of,  586 
Hysteria,  peripheral,  547 
Hystero-neuroses,  491 

I. 

Infection,  bacteria  not  essential  to,  495 
Intestinal  obstruction,  diagnosis  and  treat- 
ment of,  553 
Intestine,  foreign  body  in,  566 
Iodoform,  action  of,  542 

in  eye  diseases,  578 


Iowa  State  Medical  Society's  Transactions, 

notice  of,  520 
I  Isham,  parotiditis,  369 


No.  CLII  Oct.  1878. 


38 


594 


I  N  D  E  X  . 


J. 

Jacket,  poro-plastic  felt,  576 
Jackson,  vascular  tumours  of  female  ure- 
thra, 494 

Jacobi,  sphy^mographic  experiments  on 

the  brain,  103 
Jaundice,  essential  phenomena  of,  199 
Jeffries,  Colour-blindness,  466 
Jenks,  catgut  sutures,  585 
Jones,  Aural  Surgery,  notice  of,  234 

K. 

Kelsey,  pelvic  and  abdominal  abscess,  81 

Kesteven,  researches  in  pathology  of  nerv- 
ous system,  202 

Kidd,  haemophilia,  253 

Knee-joint,  disarticulation  of,  279 

Kohler,  oil  of  rosemary,  539 

 ,  salicylic  acid,  250 

Konig,  application  of  antiseptic  method 
when  sepsis  is  present,  263 

Kuster,  carbolic  acid,  248 

L. 

Labour,  induction  of  premature,  579 
 in  albuminuria  of  preg- 
nancy, 589 
Langenbeck,  disarticulation  at  knee-joint, 
277 

 ,  enterotomy,  26S 

Laparo-elytrotomy,  292 
Laparotomy  in    extra-uterine  fcetation, 
321 

 under  antiseptic  method,  268 

Laryngeal  hemorrhage,  submucous,  255 
Laryngismus  stridulus,  chloral  in,  255 
Larynx,  extirpation  of,  562 
 ,  narrowing  of,  by  cicatrices  fol- 
lowing syphilis,  266. 
Lasegue,  peripheral  hysteria,  547 
Leach,  scurvy  in  Arctic  expedition,  200 
Lead  carbonate,  experiments  on,  439 
Legg,  jaundice,  199 

Le  Hardy,  yellow  fever  in  Savannah,  516 
Leichtenstern,  supernumerary  mammae, 
534 

Lens,  removal  of  piece  of  iron  from,  by 

magnet,  280 
Leucocytha3mia,  myelogenic,  252 
Lewis,  morphia  and  quinia  in  malarial 

fever,  159 
Liebreich,  butyl  chloral,  540 
Limbs,  unequal  length  of  normal,  590 
Lindsay,  coloured  exudation  in  eczema, 

260 

Lingual  artery,  ligation  of,  preliminary  to 
extirpation  of  tongue,  590 

Lipoma,  removal  of  enormous,  265 

Lister,  effect  of  posture  on  peripheral  cir- 
culation, 574 

Lithotomy,  lateral,  notice  of  248  cases, 
500 

Loesch,  action  of  pilocarpine,  543 
Logan,  Physics  of  the  Infectious  Diseases, 

notice  of,  529 
Lorsen,  resection  of  ribs  in  retrocostal 

abscess,  276 
Luchsinger,  localization  of  functions  of 

spinal  cord,  247 
Liicke,  muscular  necrosis,  574 
Lusk,  chloroform  in  labour,  485 


Lyman,  dilatation  of  cervix  uteri  for  arrest 

of  hemorrhage,  484 
Lymphadenorna  with  retinal  hemorrhage, 

264 

M. 

Macario,  treatment  of  hydrocele  by  elec- 
tricity, 272 

Malarial  fever,  morphia  and  quinia  in,  159 

Mamma?,  supernumerary,  534 

Martelli,  subcutaneous  injection  of  arsenic 
in  asthma,  256 

Massachusetts  State  Board  of  Health  Re- 
port, notice  of,  512 

Mauthuer,  Lectures  on  Ophthalmology, 
notice  of,  507 

Mayr,  etiology  of  face  presentation,  581 

McIIardy,  removal  of  piece  of  iron  from 
lens  by  magnet,  280 

Messemer,  cold  water  enemata  in  diar- 
rhea, 133 

Michael,  amyl  nitrite  in  tinnitus  aurium, 

281 

Michel,  hare-lip  and  cleft  palate  in  the 

Negro,  296 
 ,  use  of  testicle  in  cure  of  inguinal 

hernia,  443 
Mills,  vaso-motor  and  trophic  affection  of 

the  fingers,  431 
Mississippi  State  Medical  Society's  Trans- 
actions, notice  of,  519 
Mitchell,  rare  vaso-motor  neurosis  of  the 

extremities,  17 
Moleschott,  iodoform,  542 
Molfese,  ergotin  in  diseases  of  bladder,  567 
Mortuary  Experience  of  N.   Y.  Mutual 

Life  Insurance  Co.,  notice  of,  240 
Muhlenberg,  severe  gunshot  wound  of 

face,  92 

Munde,  value  of  electrolysis  in  treatment 
of  ovarian  tumours,  489 

Muscles,  dislocation  of,  and  their  treat- 
ment, 573 

 ,  necrosis  of,  574 

Myelitis,  arthritis  secondary  to  acute,  572 

Myopia,  causes  of,  281 

Myositis  ossificans,  556 

N. 

Nedofil,  extirpation  of  scapula  and  part  of 

clavicle,  275 
Nerves,  reunion  and  restoration  of  divided, 

570 

Nettleship,  calcareous  film  of  cornea,  279 
Neumann,  myelogenic  leucocythasmia,  252 
Neurosis  of  the  extremities,  vaso-motor, 

17,  431 
Nichols,  filtration,  513 
Nicoladoni,  myositis  ossificans,  556 
Nigrinism,  286 

Nipples,  treatment  of  sore,  284,  583 
O. 

Obstetrical  Society's  Transactions,  notice 
of,  207 

Obturator  artery,  anomalous,  269 
Oe.'S'ton,  Medical  Jurisprudence,  notice  of, 

222 

Olliver,  spinal  gout,  253 
Opium,  belladonna,  and  aconite,  compari- 
son of,  539 


Index. 


595 


Orbital  cellulitis,  112 

Osier,  Pathological  Report  of  Montreal 

General  Hospital,  notice  of,  338 
Ovarian  tumours,  electrolysis  in  treatment 

of,  489 
Ovariotomy,  583 

 ,  antiseptic  method  in,  286,  2SS 

 ,  vaginal,  488 

P. 

Palsy,  writer's,  cured  by  strychnia,  254 
Panas,  intermittent  hydrarthrosis  of  knee, 
279 

Paracotoin  in  cholera,  553 
Paralysis,  rheumatic  facial,  galvanism  in, 
255 

 ,  spasmodic  spinal,  in  infants,  254 

 ,  spasmodic  spinal,  and  ataxy,  338 

 ,  spinal,  of  adult,  379 

Parkin,  Antidotal  Treatment  of  Disease, 

notice  of,  528 
Parotiditis,  theory  of  etiology  of,  369 
Perineal  laceration,  494 
Peter,  local  temperature  in  pleurisy,  256 
Peters,  excision  of  scapula,  100 
Pfitzer,  union  of  divided  bloodvessels,  262 
Phosphorus,  action  of,  on  globular  rich- 
ness of  blood,  367 
Pilocarpin,  action  of,  543,  544 
Pistol  shot  wound  without  perforation  of 

the  skin,  290 
Pleurisy,  local  temperature  in,  256 
Pneumonia,  tartar  emetic  in,  548 
Politzer,  Occurrence  of  Danger  in  Course 

of  Disease,  notice  of,  526 
Porcher,  ligation  of  common  carotid,  448 
Potassium  bromide,  misuse  of,  541 
Presystolic  heart  murmurs,  199 
Pregnancy,  extra-uterine,  laparotomy  in, 
321 

 ,  normal,  during  extra-uterine 

pregnancy,  282 
Puerperal  poisoning,  283 

 eclampsia,  483 

Pulse,  radial,  diagnostic  value  of  in  inno- 

miuate  aneurism,  '258 
Purgatives,  physiological  action  of,  538 
Pyanuia,  pustular  eruption  in,  559 

Q. 

Quinia,  action  of,  on  globular  richness  of 
blood, 367 

R. 

Reamy,  perineal  laceration,  494 
Rectotomy,  568 

Rectum,  syphilitic  stricture  of,  568 
Retinal  red  and  its  relation  to  the  sensa- 
tion of  sight,  190 

 hemorrhages  and  lymphadenoma, 

264 
Reviews — 

Bernard  Claude  and  his  Physiologi- 
cal Works,  161 
Browne,  The  Throat  and  its  Dis- 
eases, 451 
Clarke,  Visions,  475 
Colour-blindness,  466 
Higher  Medical  Education,  174 
Retinal  Red  and  its  Relation  to  the 
Sensation  of  Sight,  190 


Rheumatoid  inflammation  of  joints  in  wo- 
men, 284 

Rhode  Island  Medical  Society's  Transac- 
tions, notice  of,  521 

Ribs,  resection  of,  276,  562 

Risel,  gastrotomy,  563 

Roberts,  unequal  length  of  normal  limbs, 
590 

Robinson,  unilateral  atrophy  of  face,  437 
Rose,  death  from  goitre,  548 
Rosemary,  oil  of,  539 

Ross,  bacteria  not  essential  to  infection, 
495 

S. 

Saint  Bartholomew's  Hospital  Reports,  no- 
tice of,  199 

Saint-Philippe,  urethritis  following  use 
of  arsenic,  270 

Salicylic  acid,  250 

Scapula,  extirpation  of,  98,  100,  275,  296 
Schauta,  induction  of  premature  labour, 
579 

Schell,  cause  and  prevention  of  squint,  418 
Schneider,  resection  of  clavicle  and  ribs, 
562 

Schweigger,  Handbook  of  Ophthalmology, 

notice  of,  245 
Sciatica,  injections  of  nitrate  of  silver  in, 

259 

Scurvy,  outbreak  of,  in  Arctic  expedition, 
200 

See,  relative  size  of  trachea  and  bronchia, 

533 

Seminal  stains,  examination  of,  586 
Shoulder-joint,  amputation  at,  for  subcla- 
vian aneurism,  206 
Shrady,  ligation  of  lingual  artery  prelimi- 
nary to  extirpation  of  cancerous  tongue, 
590 

Schroeder,  antiseptic  method  in  ovarioto- 
my, 286 

Simon,  comparison  of  opium,  belladonna, 

and  aconite,  539 
Sims,  cholecystotomy  in  dropsy  of  gall 

bladder,  565 
Sinkler,  spinal  paralysis  in  adult,  379 
Siredey,  ergot  in  typhoid  fever,  546 
Smallpox  in  pregnant  women  and  in  foetus, 

296 

Smith,  injury  to  axilla  during  reduction 

of  humerus,  572 
 ,  new  method  of  denuding  tissues, 

295 

Sommerbrodt,  stenosis  of  larynx,  266 
 :  ,  submucous  laryngeal  he- 
morrhage, 255 
Spaying  for  fibroid  of  the  uterus,  36 

 severe  dysmenorrhea,  297 

Spiegelberg,  puerperal  eclampsia,  483 
Spinal  cord,  localization  of  functions  of, 
247 

.  Spleen ,  partial  excision  of,  296 
Steiner,  treatment  of  sore  nipples,  583 
Sterility,  causes,  583 

— ■■  ,  radical  cure  of,  493 

Stewart,  chloral  in  laryngismus  stridulus, 
255 

Stone  in  bladder,  five  hundred  cases  of,  271 
Strabismus,  cause  and  prevention  of,  418 
(  Studsgaard,  foreign  body  in  intestine,  566 


5fJ6 


Index. 


Sulphuric  acid  as  an  antidote  to  carbolic 

acid,  290 
Surmay,  enterostomy,  565 
Sutures,  catgut,  585 


Terrillon,  sudden  death  by  embolism,  540 
Testicle,  use  of,  in  cure  of  inguinal  hernia, 
443 

Tetanus,  pathology  of,  261 

Thomas,  laparo-elytrotomy,  292 

 ,  transfusion  of  milk  as  a  substitute 

for  blood,  293 
Thompson,  rive  hundred  cases  of  stone,  271 
Tinnitus  aurium,  amy]  nitrite  in,  281 
Tissues,  new  method  of  denuding,  295 

 ,  transplantation  of,  577 

Tongue,  extirpation  of  cancerous,  590 
Trachea  and  bronchia,  relative  size  of,  533 
Tracheotomy  in  diphtheria,  298 
Transfusion  of  milk  as  a  substitute  for 

blood,  293 
Trelat,  rectotomy,  568 
Tuke,  Insanity  in  Ancient  and  Modern 

Times,  notice  of,  236 
Typhoid  fever,  ergot  in,  546 


U. 

Ulcer,  varicose,  577 

Urethra,  vascular  tumours  of  female,  494 
Urethritis  following  use  of  arsenic,  270 
Urticaria  following  use  of  salicylate 

soda,  260 
Uterus,  fibroid  of,  spaying  for,  36 
galvanism  in,  50 


of 


486 


-,  acute  inversion  of,  291 
-,  cervix  of,  amputation  of,  482 
-,  flexions  of,  intra-uterine  stem 


V. 

Vagina,  congenital  absence  and  accidental 
atresia  of,  490 

Vallin,  arthritis  secondary  to  acute  mye- 
litis, 572 

Vance,  inversion  of  bladder,  445 


Van  Harlingen,  glycerole  of  subacetate  of 

lead  in  eczema  rubrum,  589 
Vaso-motor  neurosis  of  extremities,  17, 

431 

Vermont  Medical  Society'6  Transactions, 
notice  of,  520 

Verneuil,  disarticulation  of  hip,  272 

Villard,  hydatid  of  pelvis  simulating  retro- 
uterine hremotocele,  289 

Visions,  Clarke  on,  review  of,  475 

Vocal  apparatus,  artificial,  562 

Volkmann,  septic  and  aseptic  wound- 
fevers,  557 

W. 

Wegner,  extirpation  of  larynx,  562 

Wells,  ovariotomy,  583 

Welsh,  smallpox  in  pregnant  women  and 

in  the  foetus,  296 
Wheelhouse,  reunion  and  restoration  of 

divided  nerves,  570 
Williams,  membranous  dysmenorrhea,  211 
ovariotomy,  by  antiseptic  me- 


thod, 288 

Wilson,  radical  cure  of  dysmenorrhea  and 
sterility,  493 

Winckel,'  sterility,  583 

Wintcrnitz,  action  of  heat  upon  circula- 
tion, 251 

AVolfier,  removal  of  enormous  lipoma,  265 
Woodbury,  lesions  of  base  of  brain,  125 
Woronichin,  nigrinism,  286 
Wound-fevers,  septic  and  aseptic,  557 


Xeroderma,  case  of,  424 


Yellow  fever  in  Savannah,  516 
Z. 

Zahn,  transplantation  of  tissues,  577 
Ziemssen,  Practice  of  Medicine,  notice  of, 

503 

Zuckerkandl,  epicondylar  fractures  of  hu- 
merus, 278 


Date  Due 


1878 

Amei^can^ 

the  medical  sciences 


American  Journal 
f^ed  Sciences 

Voi.76-N.5 
878 


3  9088  01224  9975